Serving Beaufort, Bertie, Hertford,
Martin and Pitt County

…an innovative network that will help you better connect with and serve consumers
January 2012

 Mission: To be a consumer-centered network providing easy access to aging and disability information and services in
Beaufort, Bertie, Hertford, Martin and Pitt
County.
 Vision: Service access without confusion for all consumers.

LTC System Challenges
Purpose and Background of Aging and Disability Community Resource
Connections
Fragmented
Institutional bias
Lacks focus on consumer
Confusing
Increase in population = $$$$$
CRC Reform Strategy

Purpose and Background of Community Resource Connections
Aging and Disability Community Resource Connections… every community in the nation highly visible and trusted people of all incomes and ages information on the full range of long term support options point of entry for streamlined access to services

Maturity, Growth, and Expansion of CRCs
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Federal CRC initiative began in 2003 with three core functions
– Awareness, Assistance, and Access
Set of core expectations has grown over time
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Information, referral, and awareness
Options counseling, advice, and assistance
Streamlined eligibility determinations for public programs
Intervene in critical pathways to institutionalization
Person-centered transitions
Quality assurance and continuous improvement
AoA and CMS view CRCs as the platform to :
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Catalyze broader systems change
Promote participant-direction
Build stronger partnerships across siloed LTSS system
Intervene during care transitions from hospitals and other acute care settings
Assist with institutional transitions
Implement new initiatives (e.g., Veteran Directed Home and Community Based Services)
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Defining Characteristics of CRCs
 Seamless system from consumer perspective
 High level of visibility and trust
 Proactive intervention into LTC pathways
 Integration of aging and disability service systems
 Formal partnerships across aging, disability and Medicaid
 All income levels served
More a process than an entity

How CRCs Operate
Options
Counseling
Home and Community
Based Services
One-Stop
Access
Private
Services
Peer
Counseling
Nursing Homes/
Institutions
Employment
Services
Public
Programs
Health
Promotion

Key Partners
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•Area Agencies on Aging
• Centers for Independent Living
• Public & private aging and disability service providers
• State Health Insurance Assistance Program (SHIIP)
• Long term supports and service providers
(e.g., home health agencies, nursing facilities)
• Critical pathway providers
(e.g., hospital discharge planners, physicians)
• Adult Protective Services
• Medicaid

Effective CRC Partnerships
 Regular communication
 Written agreements
 Written referral protocols
 Co-location of staff
 Regular cross-training of staff
 Compatible IT systems
 I&R resources are shared
 Collaboration on client services
 Client data are shared
 Joint marketing and outreach activities

Every Community? ADRC Coverage
June
25-50% of state population
2011
100% of state population
75-99% of state population 1-25% of state population
50-75% of state population 0% of state population
Alaska
ME
WA
VT
WI
MT ND
Northern
Mariana Islands OR
MN
ID
SD
NY
NH
MA
CT
RI
CA
NV
WY
CO
NM
NE
KS
OK
IA
MO
AR
IL
MS
MI
PA
IN
KY
TN
OH
WV
VA
NC
SC
AL
GA
DE
MD
DC
Guam
AZ
LA
FL
Hawaii
TX
Puerto Rico

Overview of CRCs: Operational Components
• Information & Awareness
• Options Counseling
• Streamlined Access
• Person-Centered Hospital Discharge
Planning (Care Transitions)
• Quality Assurance & Evaluation

Overview of CRCs: Operational Components
Options Counseling
CRCs Provide Decision Support
Options Counseling
. . . an interactive decision-support process whereby consumers, family members and/or significant others are supported in their deliberations to determine appropriate long-term support choices in the context of the consumer’s needs, preferences, values, and individual circumstances

Overview of CRCs: Operational Components
Options Counseling
Options counseling provides consumers with the tools and knowledge they need to choose the best path for themselves.

Overview of CRCs : Operational Components
Streamlined Access
-- from the consumer’s perspective
Go somewhere else
“no wrong door” or “one stop shop” access to services and supports
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Call another organization or agency seamless referral to other agencies; consumers do not need to make another phone call
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Repeat same information over and over information systems designed so that information collected at the initial point of contact populates multiple forms
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Worry about getting “lost in the system.” follow-up after referrals are made

nComponents
Person-Centered Hospital Discharge Planning (Care Transitions)
Create linkages that ensure people have the information
-- to make informed decisions
-- to understand their support options as they pass through critical health and LTC transition points
-- hospital discharge
-- nursing or rehab facility admission or discharge

al Components
Quality Assurance and Evaluation
• Measure: consumer outcomes system efficiencies costs
• Use results: improve services identify and meet needs strengthen programs

Quality Assurance and Evaluation
Consumers have consistently reported high levels of satisfaction with CRCs
• Services
• Responsiveness
• Staff knowledge
• Information
• Capacity to make informed decisions
“I never knew that this could be so easy and pleasant.
I was expecting something far more bureaucratic and difficult.”

 a separate physical location,
 a change to existing service eligibility criteria, or
 a change or replacement of services.

 Referral Process
 Person-Centered Follow-up
 Evaluation/Customer Satisfaction

 Age 60 or above
 Age 18 or over and disabled

Am I an agency that provides any CRC services?
 Do I provide information and assistance?
 Do I provide options counseling?
 Do I conduct assessments?
 Do I provide follow-up?

 Determine customer needs and desires
 Develop a person-centered plan of action
 Explain the CRC and discuss confidentiality
 Complete the Intake/Referral Tool
 Contact the customer to determine if needs were met
 Determine next steps

 Handle the immediate request
 Explain the CRC, discuss confidentiality, and get permission to refer
 Complete the Intake/Referral Tool
 Refer to a CRC Partner
 Follow up to ensure needs are met

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Keep the consumer (or his/her caregiver) updated on progress of requests
As deliverables occur, ensure it/they meet(s) expectations
When “complete” contact consumer to confirm that initial request satisfied and determine any additional needs
Enlist consumer’s willingness to provide satisfaction feedback to CRC

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Contact consumer (or consumer’s representative)
Inquire as to adequacy of product or service delivered
Ask if she/he has any recommendations to improve the process, service, product or experience
Ask if there is any further information or assistance needed at this time

Semi-Annual Reporting Tool
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 Refer to SART Definitions
 Plan a system to count contacts
 Plan a system to count clients/consumers
 Submit data to CRC Coordinator via email by the 15 th of each month.

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This is a Process “in progress”
 The Network is Expanding
 Increased Understanding of Partner
Capabilities =
A Stronger Network =
Enhanced Consumer Service Quality =
Cost-Effective Resource Allocation