Launching Aging and Disability Resource Connection...

Launching an ADRC for Multnomah County 1

Launching Aging and Disability Resource Connection Operations For Multnomah County

INTRODUCTION

At some time in our lives, most of us will need a trusted source of information about long‐term services and supports. Even for those of us who do contact a local Area Agency on Aging (AAA) or Medicaid field office for help, 60% will not be eligible for Medicaid services and will need assistance to make other plans for long term care. This critical need has led Oregon’s Department of Human Services director Erinn Kelley‐Siel to recently announce her support for developing Aging and Disability Resource Connection (ADRC) programs across the state, all using the same standards and a common logo:

By joining the nationwide ADRC movement, Oregon is not simply adding a new service, but updating the paradigm about the Aging and Disability system’s role in the community. As described by the State, ADRCs in Oregon will change the way we do business: ● Move from a focus on eligibility, to offering a set of options in a consumer‐driven approach for all

older adults and people with disabilities. ● Build a better and more coordinated network, rather than replacing existing organizations. ● Move us from being experts working in isolation, to creation of cross‐training, routine

communication and formal partnerships that enable better coordination. ● Help to delay or avoid costly nursing home care, by assisting people to understand the alternatives

and make judicious use of their personal resources.

State Expectations

ADRC Services in Oregon will include:

● Information and Assistance

● Access to Public Benefits

● Benefits Counseling

● Options Counseling

● Care Transitions

● Health Promotion and Disease Management

A major challenge in implementing ADRCs statewide, however, is that neither the State nor federal budget provides new funding for ADRC operations. Over the past two years using funding from short term federal grants, Oregon has developed a statewide searchable resource database (at

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www.ADRCofOregon.org ) and a “call module” that allows ADRC specialists to track calls and issues. Four ADRC pilot projects were also initiated, including Multnomah & Washington Counties’ joint Community Living Program (CLP) grant. These pilot projects are now seeking to continue and expand ADRC services, with each area obtaining their own funding or redirecting current funds until the State financial picture improves. This paper describes the Multnomah County Aging and Disability Services (ADS) plan for launching ADRC operations for this community, building on work from the past two years, while continuing to participate toward regional ADRC development and designation.

ADS Progress toward an ADRC

● Community Living Program (CLP) – funded by an Administration on Aging grant from October 2009 through December 2011. Enhanced ADS Helpline services, tested delivering Options Counseling through area District Centers, developed service delivery relationships with Washington County AAA and the local Center for Independent Living.

● ADRC Project Committee – a team of ADS staff from varied positions, units and branches worked from November 2009 to present on ADRC design and service delivery models.

● ADRC Community Advisory Committee—members from consumer groups, district centers, health and community agencies, 211info and ADS reviewed and gave input on ADRC development from October 2010 through August 2011.

● Three major progress reports – produced and reviewed with all ADS advisory groups, ADS staff, and District Centers:

○ One Door Opens Many (January 2010),

○ Preparing for an ADRC for Multnomah County (June 2010), and

○ Design Options for Multnomah County (December 2010).

● Input sessions – for District Centers and other partner agencies. April and July 2011. ● Participated in regional meetings with Clackamas, Columbia and Washington counties to discuss and plan for development of a regional ADRC.

● Worked with Independent Living Resources, center for independent living, to add disability specific resources to the ADRC resource database and to develop support materials and training for our options counseling program participants.

● Subcommittees on: Communications, Cross‐Training and Evaluation.

● Pilot Project Work Groups – to test models for streamlining service access for consumers, and to design the ADRC interface between Helpline and Medicaid.

● ADRC Coordinating Committee – leadership team to evaluate research, respond to input, and guide overall planning efforts.

● Staff, partner and community input on Launching ADRC Operations report and, concepts June ‐ August 2011.

This Multnomah County ADRC Plan is based on a “no new funds” assumption for initial operations. The target is a “soft launch” of core ADRC functions on October 1, 2011. Active marketing to the general public will be delayed until funds are obtained to increase staffing for ADRC components. The first year will focus on providing ADRC services that do not require a major increase in staffing, forming partnerships and systems essential to future ADRC development, and increasing regional


coordination. ADS will identify and apply for additional governmental and foundation funding for increased service delivery and for pilot testing service improvements.

I. MULTNOMAH ADRC VISION, GOALS & PROCESS

ADRCs exist in almost every state as a cornerstone of the plan for managing our increasingly aging population. Although Oregon is one of the last states to move toward implementation, this offers the advantage of having many state models to draw from.

In other states, the ADRC is a highly visible, trusted source for unbiased information, assistance and decision support for seniors and people with physical disabilities, their families and caregivers. ADRC professionally trained Information and Assistance Specialists not only provide information, but help connect consumers to the agency or service, and follow up when needed. Access to Public Benefits is offered through direct or linked Medicaid eligibility determination in most states. ADRCs also provide Benefits Counseling and Options Counseling to assist consumers in determining what insurance and care options best fit their needs and preferences. Care Transitions, a newer component, assists people to successfully move home after hospitalization or a skilled nursing home stay. Health promotion and disease management information and resources are often provided as well.

Multnomah ADRC advisory group members examined models from many states, and developed the following vision and goals. These local goals are intended to align with State goals for ADRC development and regional ADRC implementation.

MULTNOMAH ADRC VISION We work, through the ADRC, with people to identify their needs and preferences, and explore the options and solutions available to them.

MULTNOMAH ADRC GOALS When fully implemented, Multnomah County will have an ADRC network that provides:

1. A single access point for seniors and people with disabilities of all income levels and cultures. ● One centralized phone number ● One call/one story ● Seamless service ● Regular use of warm transfers

2. Ongoing and comprehensive Information and Assistance, Access to Public Benefits, Benefits Counseling and Options Counseling to help people make informed decisions ● Personalized assistance ● Up‐to‐date resource database ● Staff knowledgeable in both public and private pay options ● Follow‐up where needed

3. A highly trusted and visible network that provides superior customer service ● Skilled, dedicated network staff ● Streamlined workloads ● Clearly established roles ● Ongoing training

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● Opportunities for career development ● Increased staff satisfaction ● Participation by peer volunteers

MULTNOMAH ADRC PROCESS ADS and partners have always provided services similar to the many of the components of an ADRC. However, now they will be formalized to new state expectations, linked together in new ways and expanded to reach additional people. The “soft launch” of ADRC operations moves the system out of a planning phase and into a delivery phase, initiating delivery of ADRC services in a more coordinated manner.

The graphic below illustrates how the ADRC would operate in a general way. Callers would contact the ADRC, either directly or after being connected by a community partner. The ADRC would provide Information and Assistance on a variety of topics. For some callers, a transfer to a specialist (such as a Benefits Counselor, Options Counselor or Medicaid Screener) would be required. While some questions will be answered without additional steps, most callers will either be connected to the resource that can help them, or receive a referral to one or more resources. Callers will receive limited follow‐up when needed.

How the ADRC Will Work


II. Multnomah ADRC Services

The ADRC in Multnomah County will look very similar to what we have now, as a key principle in the “no new funding” model is to minimize organizational change. Since most components of the ADRC are already being delivered within the ADS network, the proposal is to build on and better coordinate these existing components to create an “ADRC Team” across multiple ADS units and contracted programs. This diagram illustrates this teamwork.

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The ADRC Management Team will serve as the oversight team to coordinate delivery among the multiple programs and partners. An ADRC Partnership Team will create a framework for all agencies involved in ADRC service provision to coordinate services and plan improvements. The ADRC Advisory Council provide input on service design, delivery and quality and the majority of members will be consumers of ADRC services. The key services that will be delivered through the ADRC are:

Information and Assistance (I&A) through the ADS Helpline, which serves as the front door to information, assistance and services for people in Multnomah County who have needs related to aging or disability. Neighborhood‐based Information & Assistance may also be available at some District Centers. The After Hours contract will continue to take messages for the Helpline and respond to urgent needs when ADS offices are closed.

Access to Public Benefits: Access to public benefits will be facilitated by Helpline I&A Specialists screening for Medicaid eligibility and long term care, and linking people who may be eligible for these services to more detailed screening or intake appointments.

Benefits Counseling will be built on the existing Senior Health Insurance Benefits Assistance (SHIBA) program, providing benefits outreach and enrollment assistance to help individuals compare benefits options and complete and submit applications.

Options Counseling services for non‐Medicaid participants will continue to be provided via staff at District Centers. ADS will pilot provision of Options Counseling by ADS Medicaid staff for those having a Long Term Care (LTC) case manager.

Care Transitions services are being pilot tested this year with one hospital. Services will be delivered by ADS Transition/Diversion staff or Skilled‐Nursing Facility case managers for participants with Medicaid services, and by District Centers for others.

Health Promotion and Disease Management information and programs will continue via our work with partner agencies on promoting healthy living including promoting access to nutritious foods and nutrition education, exercise and recreation programs, and evidence based disease activities.

A. Information and Assistance (I&A)

The Helpline will service as the key access number for Information &Assistance services. Calls will be received through a single local phone number (the current Helpline number) or through the statewide toll‐free ADRC phone number. The Helpline will also develop and update local resources in the statewide on‐line database.

Information and Assistance

State Expectations ● Certified I&R staff ● Statewide website with searchable resources ● Planning for statewide toll‐free number ● Statewide brand & marketing

Multnomah Plan ● All Helpline staff are AIRS certified ● District Center I&A staff will be AIRS certified

● State site: www.ADRCofOregon.org


● In addition, one local phone number ● Local marketing to be delayed until funding improves

Information and Assistance (I&A) Definition: Information and Assistance is a service designed to support older persons, adults with disabilities, and their caregivers to assess their needs; locate and use services and resources which promote their well‐being, independence and self‐determination; and protect their interests and rights. Assistance also includes choice counseling, problem solving, care coordination, advocacy, and follow up.

Information and Assistance (I&A) Process: The ADS Helpline currently serves as the hub for Information and Assistance. Partner agencies, branch office staff and the general public call into the Helpline number to obtain assistance in identifying services and resources to meet the needs of seniors and adults with physical disabilities.

Helpline staff fully assess the range of needs a caller may have, as well as the caller’s functional, financial, health and living situation, and then identify organizations and programs capable of meeting the caller’s needs. Enough program information is provided so that the caller can make an informed choice. A warm transfer (a three way call with the referral organization) may be used to smooth the transition and ensure that the caller’s needs will be met. Sometimes a call may be made for a person.

District Center staff will provided neighborhood‐based I&A and transfer complex calls, including calls for public benefits pre‐screening and emergency services, to the ADS Helpline.

The Helpline staff also provide screening for referrals to public benefits, Benefits Counseling, Options Counseling, Multnomah Project Independence, and Care Transition services.

Multnomah County ADRC Design:

● Transition to a centralized I&A model at the Helpline to standardize consumer service. ● Primary access to I&A will be through one published local number, and the statewide number. ● District Centers will continue to provide local Information and Referral (I&R) and neighborhood

based I&A including for walk‐ins. ● ADS Helpline staff complete pre‐screening for Medicaid financial and services eligibility. ● ADS Helpline staff will screen, and complete as needed applications, for safety net programs

including emergency medications, medical special needs, emergency housing and Multnomah Project Independence services; family care giver services; and Medicare benefits.

● ADS Helpline will continue to receive and process the Options Counseling and Care Transitions referrals.

● All staff performing I&A and/or I&R functions will have AIRS Certification; new staff will complete certification within first year.

● All I&A calls will be logged in the new statewide call module. Implementation Tasks:

● Develop a plan and timeline for transition to centralized I&A. ● Increase staffing at the Helpline; replace CLP funding and further increase FTE. ● Focus on increased knowledge base and expertise of staff and quality of services. ● Coordinate with Independent Living Resources (CIL) and others serving individuals with disabilities to

increase number of disability‐specific resources in database.

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● Train District Center and Branch staff to use new statewide searchable database. ● Train District Center staff on use of statewide call module. ● Phase in AIRS Certification for any staff providing Information & Referral. ● Pilot guidelines I&A and/or I&R services provided by Branch offices and District Centers, including

for transferring I&A callers to the Helpline. ● Pilot guidelines for transferring Medicaid applicants determined not eligible for Medicaid to the

Helpline for alternate assistance.

B. Access to Public Benefits

Medicaid Screening, which facilitates access to public services, is a key component of Benefits Counseling and essential to the effectiveness of an ADRC. Access to other benefits, such as to Oregon Project Independence and Multnomah Project Independence, is also essential.

Access to Public Benefits

State Expectations

● ADRC is the single‐entry point for accessing publicly funded long‐term care programs

● ADRC staff determine functional eligibility for LTC programs

Multnomah Plan

● Helpline will streamline access to benefits including screening and intake to public services, including: ○ Medicaid – medical and financial

benefits, and long term care ○ Oregon Project Independence ○ Multnomah Project Independence

Medicaid Pilot Project Results: Pilots are currently being conducted to test the interface between the Helpline and both Medicaid Eligibility and Medicaid LTC screening. Results show that cross‐training activities, including training, shadowing and attending each other’s meetings, have improved knowledge and coordination between systems. Helpline staff are entering basic information into Oregon ACCESS so that Medicaid screeners can utilize client information that has been gathered to date, without needing to ask the caller again for the same information. Helpline staff making a referral to Medicaid attempt a warm transfer; calls that do not immediately reach an eligibility worker or service screener go into voicemail and are returned within a day.


● Helpline staff continue to prescreen for Medicaid eligibility and service, where these programs would potentially benefit the caller.

● Helpline staff continue to enter data in the Oregon ACCESS database, to provide Medicaid screeners with information that has been discussed on the initial I&A call.

● Helpline staff attempt to complete a warm transfer to Medicaid screeners, although when these staff are on the phone, a message is left.

Implementation Tasks:

● Medicaid program continue to seek ways to work toward greater efficiencies, so that warm transfers to screeners become more feasible.


● Increase staffing at the Helpline to handle increased pre‐screening. ● Decide how the Medicaid program and branches will interface with ADRC pre‐screening.

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C. Benefits Counseling (BC)

Benefits Counseling includes providing information and discussing options for health and long term care coverage, including private insurance, Medicare and Medicaid. It helps individuals and families decide about coverage, screens for eligibility and assists with applications.

Benefits Counseling

State Expectations ● ADRC is the single‐entry point for accessing publicly funded long‐term care programs

● ADRC staff determine functional eligibility for LTC programs

Multnomah Plan ● Benefits Counseling will be provided by ADRC specialists, primarily SHIBA staff and volunteers

● Benefits Counseling will be coordinated across ADS programs providing related services (emergency prescriptions, MMA)

● Helpline staff will complete an initial assessment of financial and functional eligibility by phone, referring on to Medicaid specialists when full assessment is appropriate

Benefits Counseling Definition: Benefits Counseling provides information regarding federal, state and local benefits and entitlement programs that a person with a disability or a senior citizen may be eligible for. Benefits Counseling includes helping a person understand options and possibilities, and providing decision support to make an informed choice. Benefits Counseling Process: The Helpline provides telephone I&A regarding accessing public benefits and is the single entry point to services for seniors and people with disabilities. Helpline staff are trained in the basics of public benefits and provide assisted referrals to appropriate intake points or to support services to help with applications, and refer to Benefits Counselor specialists for additional assistance. A Benefits Counselor initially works with a person to identify and verify his/her benefits, entitlements, services, and subsidies. Benefits Counseling is provided by ADS staff and a cadre of trained volunteers, who also conduct benefits outreach through community education to low‐income areas, current clients whose benefits may be eliminated by funding cuts, and medical providers. When fully developed, Benefits Counseling will be coordinated across all ADS programs where similar functions are being done, including SHIBA, emergency prescriptions and Medicare Modernization Act (MMA) counseling.


● Benefits Counseling will be coordinated across existing programs, including: ○ Helpline I&A, the ADRC “front door” which includes Medicaid pre‐screening. ○ SHIBA (Senior Health Insurance Benefits Assistance), a federal program with federal and county

funding. Volunteers provide outreach and enrollment assistance by assisting individuals to apply for benefits. (ADS staff provides training and oversight of the volunteers.)


○ Elders in Action’s (EIA) Volunteer Benefits Assistance program, funded by ADS, which will recruit and train volunteers to assist ADS case managers to help citizens apply for or retain public benefits.

○ Medicaid LTC staff providing MMA (Medicare Modernization Act) services, which includes choice counseling about applying for Medicare benefits and plans, and advising about Medicaid, as well as other insurance and programs.

○ The ADS Emergency Prescription Assistance Program (EPAP), funded by the county to provide short term medications when there are no other options.


● Increase numbers of trained SHIBA volunteers and expand scope of services. ● Develop and provide ongoing Benefits Counseling training. ● Continue to develop expanded service capability by working with Elders in Action for co‐recruitment

of volunteers to provide benefit counseling services. ● Pilot test coordination of Benefits Counseling across ADS programs (SHIBA, MMA staff, EIA and

volunteers) to take best advantage of skills and availability. ● Develop Community Partner roles; clarify when and how to make referrals. ● Examine possible roles, networking opportunities and formal relationships with:

○ ADS Veteran’s Program; ○ SOAR ‐ Central City Concern’s intensive assistance for SSD applicants; ○ Independent Living Resources (ILR) peer counselors.

● Increase volunteerism to better support people who need benefits application assistance.

D. Options Counseling (OC)

Options Counseling is currently provided through the Community Living Program (CLP) grant by designated staff at District Centers. The ADRC will pilot provision of Options Counseling by ADS Medicaid staff, who will provide OC when appropriate to Medicaid clients.

Options Counseling

State Expectations Trained OC staff provide the following:

● Support to make decisions about long term care needs

● Short‐term service coordination ● Referrals to private & public services ● Provided by telephone or in‐person, including home visits

● MDS Section Q referrals from nursing homes

Multnomah Plan

● All Options Counseling staff, whether in DCs or Branches, will complete State OC training.

● OC will be time‐limited, and may be delivered on the phone, in person, at home, or a combination

● Referrals for DC Options Counseling will come through the Helpline

● Follow‐up contact will occur 30 days after closure.

● Provide Options Counseling as appropriate for MDS Q referrals.

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Options Counseling Definition: Provide comprehensive, objective, up‐to‐date, user‐friendly information about the full range of available immediate and long range options for long term support; help individuals understand available community support options; assess needs and resources; assist them to develop and implement their choices; and empower individuals to make informed, cost‐effective decisions about long term support services. Options Counseling Process: For Multnomah County, the Helpline receives referrals for Options Counseling from the Providence Medical System (including hospitals and clinics), and from skilled nursing facilities, and transfers the referral to the nearest District Center or ADS Branch. Options Counselors meet with the program participant at the hospital, nursing facility or their place of residence and work with the participant and family members to identify the participant’s needs, preferences, strengths and values. The focus is to increase the ability of the individual to live as independently as possible in their own home and avoid nursing home placement. Based on the assessment and the participant’s priorities, the Options Counselor provides information on all known options to meet the identified needs, including information on cost of services, and helps the participant think through the impact of various options. Many of the services needed by the participant may need to be procured on a private pay basis. MDS‐Q Referrals from Nursing Homes: The MDS (minimum data set) is a form federally required from Nursing Facilities on all patients. A new question “Q” asks residents whether they would like to have assistance to move back home or to another community setting. Referrals from this form are sent to the State, and they sort referrals by county and send them on to the local AAA. The ADS Helpline receives all referrals for Multnomah County, screens for missing information and determines if this is a I&A request or whether Options Counseling is needed. If the individual is a Medicaid client, the referral is sent to the Transitions Team for follow‐up; if they are not receiving Medicaid, it is assigned to a District Center Options Counselor. Referral receipt and assignment are tracked by spreadsheet. Community Living Program Pilot Results: Between July 2010 and July 31, 2011, one hundred and five (105) participants have been served in our Options Counseling pilot project funded by the Community Living Program grant from AoA. The Options Counselors for the pilot project are staff from the nine current District Center sites that have attended additional training including a state required three‐day series. The CLP model proved to be successful; only three OC participant entered a nursing home during the time of services and none entered a hospital.


● All Options Counseling services will be on a referral basis. ● Referrals will initially come from the Providence Health System and from “MDS‐Q” referrals from

nursing facilities. When additional funds are designated for options counseling, additional referral options, including self‐referral and referrals from Portland Adventist Medical Center will be added.

● ADS Helpline staff will screen all Options Counseling referrals from outside sources. ● Helpline will continue to receive county MDS‐Q referrals; if OC is needed, send referral to Medicaid

LTC Transitions Team or to a District Center Options Counselor. ● District Centers will provide Options Counseling for people without Medicaid. ● District Centers and any Long Term Care units doing OC will designate a lead and back‐up Options

Counselor.


● All Options Counselors will complete the state required training series provided by PSU, prior to receiving any assignment or delivering services.

● All ADS and District Center staff providing Options Counseling will meet state and county specified qualifications.

● All OC services will be narrated and tracked in the State‐approved database. ● Funding for Options Counseling will come initially from existing redirected funds, after the end of

the Community Living Program grant in December 2011. The state and the Administration on Aging (AoA) are encouraging AAAs to re‐direct some of the AoA Older Americans Act funding to support options counseling provision.


● Identify and clarify who is eligible for OC and what triggers a referral for OC services; match with service capacity and expectations.

● Bring new State standards for Options Counselors into our practice. ● Re‐direct part of the Older American’s Act and local funding to support options counseling services. ● Transition to State Options Counseling database module (being developed with RTZ). ● Pilot test having Medicaid LTC staff provide OC for Medicaid clients in the course of their work

(Transition/Diversion Team and Skilled‐Nursing Facility case managers). ● Seek funds to continue to refer OC participants to Independent Living Resources for coaching on

hiring and managing in‐home care workers. ● Pilot test providing OC to individuals who apply for Medicaid LTC but are not eligible. ● Seek funding to increase capacity and staffing to provide OC. ● Develop private case management relationships and options for delivering long term support to

consumers (since OC cannot do case management). ● Assist District Centers in research and development of fee‐for‐service programs to augment Options

Counseling.

E. Care Transitions (CT)

Care Transitions supports people as they move from one care setting to another, with a goal of reducing the potential for an unnecessary hospital readmission. This service helps individuals take an active role in their health care and recovery after returning home from a hospitalization or Skilled Nursing Facility stay.

Care Transitions

State Expectations

● Establishing formal links between health care providers and ADRC services

● Conduct demonstration projects ● Oregon Transitional Care Collaborative – community teams working to improve cross‐setting transitions

Multnomah Plan

● Establish formal agreement with health care providers

● Conduct six month pilot with Adventist Medical Center and two skilled nursing facilities

● Train Care Transitions Coaches (Coleman Model)

Care Transitions Definition: Care Transitions models focus on short term interventions that promote a reduction in hospital readmissions. Participants are first engaged while in acute care settings and then

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followed intensively over a period of approximately four to six weeks after discharge to the community. The goal is to ensure that patients and their caregivers understand how to adhere to post‐discharge instructions for medication and self‐care, recognize symptoms that signify potential complications requiring immediate attention, and make and keep follow‐up appointments with their primary care physicians. Oregon has selected the Coleman model, a 30‐day intervention, to use in our state to deliver service. This is a 30‐day intervention design to reduce number and frequency of hospital readmissions. Care Transitions Process: ADS will implement a Care Transitions demonstration project with Portland Adventist Medical Center, Cascade Terrace Nursing & Rehabilitation and Village Health Care Skilled Nursing Facility. The pilot will begin on July 1, 2011 and last six months. Representatives from each partner have been meeting since January 2011 to develop the pilot model and protocols. All referrals for Care Transitions will go to Helpline staff who will enter the referral information into our ADRC database. The Helpline will assign the referral to a trained Care Transition coach and send an alert to the coach. The Coach will contact the referred party within one business day to set‐up a home meeting. The coaching services include one home visit and three follow‐up telephone contacts. The coach focuses on four areas with the participants: medications review, follow‐up appointment with primarily care giver and transportation to that appointment, knowledge of warning signs/red flags for complications, and completion of a person medical record.


● Care Transition Demonstration Project: implement by July 1, 2011 and monitor the six‐month pilot with Portland Adventist Medical Center. Initially three staff from Long Term Care and three from District Centers will serve as Care Transition coaches.


● Incorporate anticipated State standards into local processes. ● Coordinate with Home Health, to avoid confusion and duplication. ● Designate lead staff person to attend Coleman Model Training in Colorado. ● Hold regular meetings with pilot partner groups; Adventist Medical Center, Cascade Terrace Nursing

& Rehabilitation and Village Health Care Skilled Nursing Facility. ● Adjust protocols and process as needed during pilot ● At conclusion of Care Transition Pilot, analyze results, refine process, seek new funding and expand

to new partners. ● Identify where future referrals for CT will come, and route for referrals.

F. Health Promotion and Disease Prevention

Our healthy living education and service efforts include delivery of information about and access to programs about safety, wellness, evidence‐based health promotion and disease management. The Helpline maintains referral resources for wellness and healthy aging in the statewide database, which will be broadened to encompass healthy living for people with disabilities. Additionally, ADS Community Services is also actively involved in delivery of services that target wellness activities and has partnered with community based organizations to offer health and prevention programs such as:


Chronic Disease Self ‐Management for older adults; older adult access to healthy food at senior centers and senior meal sites through gardening, cooking classes and healthy snack policies; raising of awareness of individuals with disabilities and seniors about gleaning and also regarding the farmer direct nutrition coupon program for purchases at farmer’s markets.

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● Chronic disease self‐management and other evidence‐based prevention programs including falls prevention will continue to be offered in cooperation with our community partners and other county agencies.


● Seek additional funding for Healthy Eating/Active Living activities in coordination with the County Health Division.

● Add requirement to District Center contracts for evidence‐based health promotion and disease prevention services.

● Investigate new contract and opportunities for expanding evidence‐based health promotions and disease prevention activities for culturally diverse populations.

III. ADRC Management

The State ADRC Strategic Planning Initiative (SPI) identified four goals for ADRC management.

ADRC Management

State Expectations ● Engage local service users and caregivers in shaping an excellent, ethical delivery system.

● Build in sustainability from the start. ● Increase consumer, legislative, private sector and public awareness about ADRC’s mission and services.

● Continuously improve quality of ADRC services and outcomes for consumers.

Multnomah Plan ● Form an ADRC advisory committee with at least half consumer representative members, to begin October 2011.

● Develop the ADRC program with stable ongoing funding, expanding services as additional funds become available.

● Initially limit marketing activities to target those most in need of ADRC services; match expansion of marketing to ability to meet demand.

● Develop an evaluation plan to assess quality of all components, as well as progress compared to baseline data.

● Keep informed about ADRC best practices, work on improving access and quality of service for clients, and explore new approaches for doing ADRC business.

Management for Multnomah ADRC operations is being designed in a way to allow ADRC services to begin for Multnomah County residents, while also allowing transition to a regional ADRC when that structure is developed. Multnomah ADRC will reach out to our county Mental Health Division and Developmental Disabilities Division and DCHS leadership to discuss implementation of the ADRC, population served, continued coordination of services and strengthening of relationships.


Regional Coordination: The State’s SPI identified a preference for regional delivery of ADRC services. ADS is actively working with Clackamas, Columbia and Washington county AAAs to discuss how the four counties might work more effectively together, especially given the Portland metro’s overlapping hospital and long term care service areas. However, given the “no new funding” assumption, ADRC projects and regional design will need to be phased in.


● An ADRC Management Team will be formed to coordinate among the programs delivering ADRC services, including Medicaid managers with key linkage roles.

● An ADRC Partnership Team will be formed to provide a framework for all agencies involved in ADRC service provision to coordinate services and plan improvements.

● Community Services will be charged with the lead role in implementing ADRC Management and Partnership Team decisions during the “soft launch” period. The Community Services manager will be named as ADRC director to oversee the ADRC network; a supervisor position will be added to help coordinate day‐to‐day activities.

● A new ADRC Advisory Council will be formed to begin in October, replacing both the Community Advisory Council and ADRC Project Committee. Membership will consist of consumers (seniors and people with disabilities), representatives from cultural and ethnic specific groups, community partners, and ADS staff and managers, with a majority of members representing ADRC constituent users.

● The initial funding plan will utilize and redirect existing funds for core ADRC activities.


● Increase the focus on regional ADRC planning and development activities, working toward regional designation as an ADRC.

● Evaluate the effectiveness of the current communication methods being used, including the periodic communications and in‐person presentations.

● Develop ongoing means to communicate roles, developments and outcomes to ADS and partner staff and advisors.

● Develop ongoing communication and involvement with communities representing people with disabilities.

● Develop ongoing communication and involvement of communities representing ethnic and cultural specific populations.

● Continue to plan for and implement technology improvements that support ADRC goals, including the state‐required Call Module and upgraded county phone system.

● Design and implement an evaluation plan, along with the information technology systems to support needed data collection and evaluation.

● Design future marketing plan.

IV. Next Steps

This “Launching ADRC Operations” Plan was shared throughout July with core stakeholder groups: ADS staff, District Centers and other key partners, and the three key ADS advisory groups: Elders in Action,

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the Disability Services Advisory Council (DSAC) and the Multi‐Ethnic Advisory Council (MAC). Attendees were asked for input, which was shared at a final joint meeting of the CAC/PC to advise the Coordinating Committee on recommended changes to the plan. The recommendations received from the joint committees were incorporated into this document in August 2011. The ADS Leadership Team will decide on the final plan and staffing for Multnomah ADRC operations. Over the summer, management roles will be restructured in ADS Community Services, and the ADRC Management Team and Partnership Team formed. A detailed workplan and timeline to implement and coordinate services discussed in this plan will be developed. The ADRC will make a “soft launch” announcement in October to ADRC team members, their organizations and the ADS network, indicating that core ADRC operations are on line. The table below highlights some of the key markers for continuing development of Multnomah ADRC services. As mentioned at the beginning, this schedule is based on a “no new funding” assumption. However, if federal, state or local funding is reduced in key programs, progress will likely be slower than projected below. Since grant funding could enable more to be done sooner, ADS will continue to seek additional support that may become available.

Timeline for Service Roll‐Out

Time Development Activity

July ‐ Sept 2011

Form ADRC Management and Partnership Teams; form ADRC Advisory Committee; restructure Community Services roles; develop detailed workplan and timeline to implement the ADRC plan; complete Medicaid Screening and Reception pilot projects and assess results. Continue regional ADRC planning.

Oct ‐ Dec 2011

Soft opening of primary ADRC operations announced to ADS staff and partners. Complete CLP Project, assess results and implement in ongoing Options Counseling services; Complete Care Transitions Pilot with Adventist Medical Center.

Jan ‐ March 2012

Assess results of Care Transition pilot and integrate into ongoing services. Implement pilots for Options Counseling in Medicaid LTC.

April ‐ June 2012

Implement pilots for coordination of Benefits Counseling across ADS programs.

V. Providing Input

If you wish to discuss any of these elements further, please contact:

Lee Girard (503) 988‐3768

[email protected]

Vikki Rennick 503‐988‐3620, ext. 22314 [email protected]


Multnomah County, Department of County Human Services Aging and Disability Services Division

August 2011

Launching Aging and Disability Resource Connection...

Documents

Transcript of Launching Aging and Disability Resource Connection...