MFP: California Community Transitions

1
MFP California Community Transitions

• Preference
• Interview
• Tool

2

• Use of the Preference Interview for
• the transition of inpatient facility
• residents to community living.

3
PREFERENCE INTERVIEW TOOL

• A screening instrument used to determine a
  residents
• Preference to transition
• Ability to transition
• Feasibility of transition
• Service needs for transition and community living

4
Preference Interview Training Session Overview

• What is Transitioning?
• Your Role as Interviewer
• Identifying Potential Transition Participants
• Conducting the Preference Interview
• Eligibility Criteria
• Minimum Data Set (MDS)
• Referrals

5
Session Objectives

• At the end of this training you will be able to
• Understand your role in the process
• Identify Potential Transition Participants
• Determine Cognitive Impairment
• Conduct a Preference Interview
• With a Resident
• With a Proxy
• Prepare a Referral Packet

6
What does TRANSITIONING mean?
7
Reasons people choose to transition into the
community

• Individuals right
• Promote independence
• Avoid institutional setting

8
Who is eligible to transition under the CCT

• Recipients of custodial health care services
  for at least 6 months.
• Medi-cal recipients for at least 30 days before
  participation.
• People of all ages.

9
The road to the community

• Identify an individuals preference to
  transition.
• Assess an individuals service and care needs.
• Develop Comprehensive Service Plan to meet
  individuals needs.

10
Your Role in the Transition Process

• Establish relationship with inpatient facility
  administrative staff and community agencies.
• Conduct preference and stability interviews.
• Assess residents needs and feasibility of
  transition.
• Coordinate needed services.

11
Identifying Transition Candidates
12
Minimum Data Set (MDS)

• Physical and psychological profile of resident
• MDS data needed to assess level of care
• Two types of MDS
• Full MDS
• Complete data set
• Annual or Change of Condition
• Quarterly MDS
• Subset of MDS data points
• Compiled every three months
• Copy of most recent FULL MDS required
• Copy of Quarterly needed if most recent MDS

13
Identification of Potential Transition
Participants

• Obtain names from
• CCT project Team
• Nursing Facility Staff (Social Worker or
  Business Office)
• Referrals

14
Getting Started

• Determine persons cognitive level using the
• MDS Recall Sub-scale. Scoring determines
• who will receive the initial interview.

15
Determining Cognitive Impairment

• MDS Recall Sub-scale
• 1. The current season
• 2. Location of own room
• 3. Staff names and/or faces
• 4. Awareness of being in a nursing home
• SCORING Each correct response 1 point
• Total points
• 2 4 administer resident interview
• 0 1 administer proxy interview

16
Interview Basics
17
Basic Interview Techniques

• Greet person warmly using a calm voice.
• Smile and speak clearly.
• Use residents name.
• Identify yourself and state why you are visiting.

18
Basic Interview Techniques (continued)

• Ask permission to speak with resident.
• Choose a quiet, private location outside of
  residents room to meet free of distractions
  (such as television or radio programs), if
  possible.
• Observe and consider the persons facial
  expressions and body language.

19
Basic Interview Techniques (continued)

• Be aware of interviewees physical and/or
  cognitive limitations.
• Use conversational-type interaction. Too much
  social interaction can sidetrack the interview,
  or misrepresent the visit as a social call.
• State current care and services will not be
  affected by anything said at this interview.

20
Basic Interview Techniques (continued)

• Assure resident that information given to
  interviewer will remain private and confidential,
  unless interviewer is legally required to
  disclose information for persons health and
  safety.
• Be aware of your facial expressions and body
  language.

21
Basic Interview Techniques (continued)

• Check to make sure you and resident are
  comfortable before starting.
• Check partway through questions to see if
  resident is tiring. If resident is too tired to
  continue, reschedule another session to complete
  survey.

22
Background Information
23
A Word About HIPAA

• Residents personal
• information is protected.
• Resident or proxy must
• grant permission.
• Informed, written and
• signed HIPAA consent form.
• HIPAA consent required for
• outside agencies.

24
A Word about Housing
25
Demonstration Participation

• Residences must adhere to the following
• federal requirements
• A single family home, duplex or condominium.
• A rental apartment with lockable entry/exit, with
  living, sleeping, bathing and cooking areas under
  participant/familys control.
• A subsidized housing unit or apartment.

26
What about 24 hour care?

• Is 24 hour care available in the community?
• 23/7 care is available through the NF/AH Waiver.

27
Preference Interview Process
28
Preference Interview Process

• Introduce yourself
• Explain that the interview provides an
  opportunity for a resident to express their
  preference to transition.
• Explain that resident has the right to refuse or
  discontinue interview at any time.

29
Basic Interview Techniques (continued)

• State interview does not guarantee transition to
  community living.
• Explain the following
• -Type of questions asked.
• -Length of time to take.
• -Use of a script
• -You will be writing response answers on survey
  papers you use.

30
Preference Interview Process (Continued)

• Restate the following information
• Right to refuse or discontinue interview
• Confidential and private
• No guaranteed outcomes

31
Interview with Resident

• In person
• Meet with them at the facility
• Use script
• Attempt contact at different times during day
• Log all attempts
• No more than 5 attempts

32
Interview with Proxy

• In person meet at nursing home.
• By telephone - initiate call.
• Process
• Use script
• Attempt contact at different times during day
• Leave detailed message
• Log all attempts
• No more than 3 attempts

33
Preference InterviewA look at the Questions
34
Interview Overview

• Interview is designed to be conducted as a
  conversation. Areas are queried
• History
• Ability
• Preference
• Self-Assessment
• Feasibility

35
Question 1 History

• What led to residents current stay in nursing
  home?
• Medical health change
• Post-surgery rehabilitation
• Change in physical status
• Long illness
• Need 24 hour care
• Money problems
• Provide insight into support network

36
Question 2 Ability to Transfer

• Initial perception of residents ability to
  transfer.
• What are the reasons for this perception?

37
Question 3 Preference to Transfer

• Does resident WANT to leave nursing home?
• Reasons for wanting to remain in nursing home.
• Distinction between Ability and Desire.

38
Question 4 Living Options

• Present alternative living options in community.
• Provide education about options.
• Enables informed decision.

39
Question 5 Service Options

• Present list of services available in community
• Educate about wide range of services
• Enable informed decision
• Re-assess decision to leave nursing home
• YES continue with interview
• NO end interview

40
Question 6 Housing and Support

• Feasibility of transition
• Housing options
• Existing housing options
• Affordability
• Adequate support network
• Alternatives
• Private home
• Senior apartment

41
Questions 726 Service Needs Assessment

• Instrumental Activities of Daily Living (IADLs)
• Communication
• Meals
• Medication
• Housekeeping
• Shopping
• Transportation
• Finances

• Activities of Daily Living (ADLs)
• Transfer
• Mobility
• Toileting
• Hygiene
• Grooming
• Dressing

42
Service Needs Assessments

• Systematically Identifies Needs
• Influence Decision to Transition
• Research vs. Operational Format
• Research limited probing
• Outside agency assessment (IHSS)
• Operational format more in depth
• Provide better sense of resident need from start

43
Questions 7-19Activities of Daily Living

• Determine if nursing services are needed
• Risk of overestimation of ability or unrecognized
  assistance
• Tasks broken down into smaller components
• Survey residents room for assistive devices
• Performance of task in last 7-14 days
• Dont take NO for an answer

44
Question 7 Transfer Assistance

• Help getting out of bed?
• Set up only (positioning of side rails,
  wheelchair)
• Supervision
• Limited assistance (non or light - weight bearing
  support)
• Extensive/total assistance (significant or total
  weight bearing support)
• Probe all responses

45
Questions 8 9 Meal Assistance

• Help getting started to eat?
• Cutting up food
• Opening cartons
• Getting silverware

• Help eating?
• Food Intake assistance
• Use of special utensils and/or cup

46
Question 10 Bed Mobility

• Resident need assistance to turn in bed?
• Bed rails count as assistance

47
Question 11 Toileting Assistance

• Sensitive subject
• Help getting to toilet?
• Adult briefs or pads?
• How often briefs or pads?
• Help changing briefs or pads?
• Use of briefs/pads ? inability to use toilet

48
Question 12 Toileting Assistance Frequency

• How often assistance is required during day
• Getting to the toilet
• Changing adult brief/pad
• Identify points in day assistance received
• Morning (before/after breakfast)
• Afternoon (before/after lunch, before dinner)
• Evening (after dinner, before bed)

49
Questions 13 14 Grooming and Hygiene

• Assistance with morning grooming
• Brush teeth
• Wash face
• Comb hair
• Assistance with bathing
• Shower
• Bath

• Level of assistance
• Set-up only (i.e., toiletries laid out)
• Supervision
• Limited (resident performs most activities)
• Extensive/Total (resident dependent on nurse
  aides for most or all activities)

50
Questions 15, 16 17 Mobility

• Help walking Inside/Outside
• Specify type of assistance
• Cane
• Walker
• Safety rails
• Wheelchair Inside/Outside

51
Questions 18 19 Dressing

• Assistance to dress and undress
• Able to put on/remove
• Shoes/socks
• Reach feet
• Tie laces

• Shirt/dress
• Buttons
• Zippers
• Pants
• Bend
• Pull
• Fasten

52
Question 20-26 Instrumental Activities of Daily
Living (IADLs)

• Auxiliary services needed to function in
  community
• IADLs currently performed by Nursing Home or
  family
• Probe responses

53
Question 20 Communication

• Help using telephone?
• Volume increase
• Large numbers
• Dialing assistance
• Does resident use an amplifier?

54
Question 21 Meal Preparation

• Help cooking or preparing meals?
• In their own household
• Use or operate appliances, i.e., microwave

55
Question 22 Medication Management

• Help with medications?
• Read labels
• Open packaging/
• bottles

56
Question 23 Housework

• Help with housework?
• Laundry
• Washing dishes
• Stand for extended period of time
• Cleaning house
• Bend over

57
Question 24 Shopping

• Help with shopping?
• Type of help?
• Reach shelves
• Place things in basket

58
Question 25 Transportation

• Help with transportation?
• Type of transportation
• Frequency of transportation

59
Question 26 Financial Management

• Help managing money or finances?
• Paying bills
• Balancing checkbook
• Tracking bank accounts

60
Question 27 Feasibility

• If needed services are available in community, is
  resident able to leave nursing home?
• Response determines course of action

61
Where to after question 27?

• Interviewees response determines next step in
  identifying transition candidates
• Primary Interview with Resident
• YES or NO
• Conduct second preference interview in 2 weeks
• Primary Interview with Proxy
• YES
• Conduct second preference interview in 2 weeks
• NO
• Final response
• No transition

62
Interviewers Perception of Residents responses
63
Questions 28 29 Impressions

• Interviewers perception
• Post-interview
• Measure interviewers confidence in residents
  response
• Understanding of what services are needed process
  (Question 28)
• Level of motivation to relocate (Question 29)
• Optional

64
Stability of Preference to Transition
65
Stability of Preference to Transition

• Determination of preference stability is
  evaluated twice using the Preference Interview
  both times.
• 1st interview Preference is assessed and
  information is shared on transition issues and
  services.
• 2nd interview Preference is assessed and how
  transition issues and services will affect them
  in a potential transition.

66
Determining Residents Stability Of Preference
to Transition

• Not Stable if
• Resident responded NO to question 5 .
• Resident responded No to question 27.

• Stable if
• Resident responded YES to question 5.
• Resident responded YES to question 27.

67
Second Interview

• Repeat Preference Interview with Primary
  Interviewee 2 weeks after primary interview

68
Second Interview (Continued)

• Primary interviewee determines who secondary
  interviewee will be
• If primary interviewee is RESIDENT, then
  secondary conducted with potential caregiver.
• If primary interviewee is PROXY, then secondary
  conducted with resident.
• Permission is required.

69
Two Interviews Now What?

• Do findings show
• Preference Stability
• Initial preference does not change over time.
• Measure desire and commitment to transition.
• Transition Eligibility
• Permission to refer
• HIPAA consent

70
Preference Interview Findings
71
Person is a candidate for transition if

• Resident or Proxy responded YES on two
  consecutive interviews
• Primary YES
• Secondary YES

• Agreement among resident, proxy, and/or family
  regarding transition preference shows stability.

72
PREFERENCE YES

• Ask residents permission to refer for possible
  transition and participation in demonstration.
• Obtain signature on Participant Information Form
  to review process.

73
Person is a possible candidate for transition if

• Resident responded YES on 2nd interview
• Primary NO
• Secondary YES

• A third interview may be needed to discuss
  transition issues and confirm findings.

74
Person is not a candidate for transition if

• Resident responded No to 2nd interview
• Primary Yes
• Secondary No

• Leave contact information with resident/ support
  person in case future contact is requested.

75
Transitioning Referral Packet

• MDS copy(s)
• Permission to Refer
• HIPAA consent form
• Copies of Interviews
• Resident Summary

76
Permission to Refer

• Once the preference to transition to community is
  established, interviewee must provide written,
  informed permission to have information forwarded
  to transitioning agency.
• Permission to Refer form is standardized notice
  signed by interviewee.
• Presented to interviewee once stability
  interviews are complete.

77
Resident Summary

• Demographics Name, DOB and AGE
• Significant considerations
• Physical (i.e., wheelchair)
• Medical
• Psychological
• Consent status
• Proxy name and contact information
• Potential caregiver name and contact information
• Housing information
• Housing preferences
• Desired locations
• Amount willing/able to pay
• Interviewer impressions (Questions 28 29)

78
Final NoteInter-Rater Reliability

• Agreement between interviewers
• Necessary
• Establish reliability among all interviewers
• Pair up interviewers
• One interviewer conducts interview
• Other interviewer audits
• Minimum 80 agreement

79
Interview Practice

• Role play
• Interviewer
• Resident
• Inter-rater reliability test

80
Questions and Discussions