June 10, 2015 1-3PMDischarge Planning Goal

Local Contact Agency (LCA)

SECTION QPARTICIPATION IN ASSESSMENT AND

GOAL SETTING

Objectives

Understand this section records the participation and expectations of the resident, family as related to overall goals

Understand how to code Section Q correctlyUnderstand what needs to be on the care

plan

Q0100: Participation in Assessment Actively engages in interviews and conversations as necessary to meaningfully contribute to completion of MDS 3.0

Q0100: Participation in Assessment (MDS)Family or Significant Other

Spousal, kinship (e.g., sibling, child, parent, nephew) or in-law relationship

Partner, housemate, primary community caregiver, or close friend

Not nursing home staff, unless they are a family memberGuardian - Appointed by court

Authorized to make decisions instead of resident Includes giving and withholding consent for medical

treatmentLegally authorized representative

Designated by resident under state lawMakes decisions on resident’s behalf when resident

unableMedical power of attorney

Q0100: Participation in Assessment (MDS)

A. Resident participated in assessmentCode 0. No. Did not actively participate in

assessment processCode 1. Yes. Actively and meaningfully

participated in assessment process

Q0100: Participation in Assessment (MDS)

B. Family or Significant Other participated in assessmentCode 0. No. Did not participateCode 1. Yes. Did participate Code 9. Resident has no family or

significant otherC. Guardian or legally authorized representative

participated in assessmentCode 0. No. Did not participateCode 1. Yes. Did participate Code 9. Resident has no guardian or legally

authorized representative

Q0300: Resident’s Overall Expectation

What does resident want to be outcome of stay in the nursing home, including returning to community;

Ask to consider current clinical status, improvement or worsening, social supports;

Provide options and information to help in decision making;

Encourage involvement of family or significant other in discussion if resident consents.

Q0300: Resident’s Overall Expectation

• Complete only if first assessment (OBRA, PPS, or Discharge) since most recent admission A0310E = 1• Record expectations as expressed, whether realistic or not

Guardianship Situations

In some guardianship situations, the decision-making authority regarding the

individual’s care is vested in the guardian.

But this should not create a presumption that the resident is not able to

comprehend and communicate their wishes.

Q0400: Discharge PlanSafety evaluation of place going to live,

assistive/adaptive devices, medical supplies, equipment, homemaker services, meal preparation, ADL assistance, transportation, prescription assistance, financial assistance eligibility, family involvement and support available

Q0400: Discharge Plan

A. Is there an active discharge plan in place for resident to return to community?Code 0. No.Code 1. Yes. SKIP to Q0600 referral

Q0490:Preference to Avoid Being Asked Question Q0500B

(Complete only if A0310A = 02, 06 or 99)

Code 0, no: if there is no notation in the resident’s clinical record that he or she does not want to be asked Question Q0500B again.

Code 1, yes: if there is a notation in the resident’s clinical record to not ask Question Q0500B again, except on comprehensive assessments.

Code 8, Information not available: if there is no information available in the resident’s clinical record or prior MDS 3.0 assessment.

(If this is a comprehensive assessment, proceed to item Q0500B, regardless of the previous responses to item Q0550A.)

Q0500: Return to Community

Initiate and maintain collaboration between nursing home and Local Contact Agency (LCA) to support resident transition.

Ask resident if would like to talk to someone about the possibility of leaving this facility and returning to live in the community.Explain will not require to leave facility or promise

that will be able to leave. Explore possibility of different ways of receiving

ongoing careIf unable to communicate preference, contact family,

significant other, guardian or legal representative

Q0500B: Return to Community?Ask the resident (family, significant or

other, or guardian, or other legally authorized representative if the resident

is unable to respond)

Q0550: Resident Preference to Avoid Being Asked Question Q500B Again

Q0600: Has referral been made to local contact agency?

(Document reasons in resident’s clinical record)

Code 0. No-referral not neededCode 1. No-referral is or may be needed (For

more information see Appendix C, Care Area Assessment Resources #20)

Code 2. Yes, referral made

Q0600: Has referral been made to local contact agency?

Local contact transition agency provide information of long-term care (LTC) community options and supportsAAA – populations 65 years old and olderCILs – populations 64 years and 11months

and younger Provider Information

Lacey Vaughan – 785-296-0385lacey.vaughan@kdads.ks.gov

Requirements for Discharge Collaboration

NF Staff (Social Worker or Discharge Planner) initiate contact to LCA for residents who express desire to learn about possible transition back to community

LCA respond by providing information to resident about available community-based LTC supports and services

NF staff and LCA engage resident in discharge and transition plan and collaboratively work to arrange all needed community based services

Care Plan Considerations

State the discharge goalInclude what needs to happen to reach the

goalWhat staff needs to do to help the elder reach

their goal, i.e. have elder do as much for themselves as they possibly can

Questions?

I’ll take the next few minutes to answer any questions you might have

Thank you!!

Please feel free to contact me

Shirley L. Boltz, RNRAI/Education Coordinator

785-296-1282shirley.boltz@kdads.ks.gov