5024 Primary Duties | ACCESS-TO-SERVICES-5200-MANUAL

Georgia Division of Aging Services
Access to Services Manual

Chapter:

5000 Aging and Disability Resource Connection (ADRC)

Effective Date:

Section Title:

Primary Duties

Reviewed or Updated in:

MT 2021-01

Section Number:

5024

Previous Update:

Summary Statement

The comprehensive, streamlined access system provides the following services. The components are inter-related and require that current and future staff be cross-trained on all aspects of the access service system.

Standards

Information Provision: Staff shall provide information to inquirers in response to direct requests for information.
1. Staff shall request the name and telephone number at the beginning of a telephone call, in case the caller is disconnected.
2. Staff shall encourage the inquirer to re-contact the agency if information provided proves to be incorrect, inappropriate or insufficient for needed services/resources.
3. Information provided shall be accurate and pertinent to the request.
4. Information provided may range from limited responses (organization names, addresses, telephone numbers) to detailed information about community service systems (explanations of application processes, agency policies, etc).
5. Staff shall enter basic client information into the DAS Data System for all inquiries (telephone, email, fax, walk-ins).
6. Faxes, email, and other correspondence sent to the ADRC from home health agencies or hospitals for the discharge planning process do not require telephone contact except when requested by a potential client. A letter mailed to the client explaining the AAA/ADRC and services offered is sufficient. Basic client information must be entered in the DAS Data System.
7. Counselors must explain to all callers that individual clients will not be placed on a waiting list without their knowledge and consent except in cases where the individual cannot give consent, allowing the Counselor to provide Information and referral and to complete the assessment with the caller or other representative without first speaking with the individual in need of services.
Referral Provision: Staff shall provide referrals that address needs communicated by the inquirer, as openly and non-obtrusively as possible and allow inquirer to choose from a variety of service options. ..The referral process consists of:
1. Identifying the needs of the inquirer;
2. Identifying appropriate resources to meet the stated need;
3. Providing enough information about each resource to help inquirers make an informed choice;
4. Helping inquirers for whom services are not available identify alternative resources; and,
5. Actively participating in linking the inquirer to needed services, including warm transfers when necessary.
Assistance: The Area Agency shall ensure information is provided through a variety of formats and media, accommodating language barriers and literacy issues, including supported access through an access system staff member or case manager, also including access to staff in other organizations, and additional options for independent access by inquirers.
Advocacy/Intervention^[1]: The Area Agency shall offer advocacy to ensure people receive the benefits and services to which they are entitled and organizations within the established service delivery system meet the collective needs of the community.
1. The AAA will develop guidelines for staff providing advocacy on behalf of individual inquirers, including obtaining permission from the inquirer to proceed with making contacts on his/her behalf.
2. Individual/Client Advocacy: Staff shall intervene on behalf of an individual to help establish eligibility and obtain appropriate services; when the individual needs assistance communicating their needs to a service provider or otherwise effectively representing themselves; or when they have a complaint about a service delivered through the ADRC network.
3. System Advocacy: The agency shall advocate for changes in community conditions, structures, or institutions when modifications in the service delivery system are required to ensure the adequacy and availability of essential community services. Such advocacy may be based upon the collection, analysis and dissemination of data on human service needs.
Follow-up: The Area Agency will develop protocols for ADRC or other administrative staff for follow-up contacts with inquirers on a routine basis, under the following circumstances:
1. Mandatory follow-up in situations when endangerment is suspected and when ADRC staff believe that an inquirer may not have the necessary capacity to follow through and resolve his/her own problem.
2. Staff will conduct follow-up only with the permission of the inquirer and only in situations in which the inquirer will clearly benefit from such actions (except for sampling for program evaluation purposes). Follow-up contacts shall also establish the consumer’s satisfaction with the information provided, as a measure of program effectiveness.
3. Follow-up also may entail contacting the inquirer and/or an organization to which a referral was made to determine whether services are being provided, inquirer needs are being met, and when services are not provided.
4. Staff will verify information gathered through follow-up contacts; information shall be used to correct any errors or outdated information in the resource database.
5. If the inquirer has not received appropriate services or the need has not been met, staff will reevaluate remaining needs and make additional appropriate referrals. Staff shall document follow-up contacts and results in the DAS Data System.
6. Information obtained through the follow-up process shall be considered when evaluating the effectiveness of existing community service providers and when identifying gaps and duplications or overlaps in community services. Also see 5032 Accountability and Quality Improvement.
Intake and Assessment is the component of the access system related to contact with applicants to determine their priority and eligibility for appropriate service options available through all aging network programs and services, excluding the Long-Term Care Ombudsman Program and the GeorgiaCares programs. Staff shall be knowledgeable of and coordinate their activities with these programs when consumers would benefit from being referred to them. Access system staff will direct callers requesting services to appropriate agency staff and/or provider agencies and document the transactions in the DAS Data System. For all consumers, except those noted above, staff will evaluate clients’ service needs and preferences. After determining that client meets criteria for assessment, agency staff shall identify the client’s service needs and preferences with the following assessment tools.
1. Assessment Instruments: Staff will establish an individual record in the DAS Data System for each client assessed.
  1. Staff shall use the Triage Tool to gather baseline information from applicants (or their representative) surrounding basic prioritization criteria for Older American’s Act (OAA) Home and Community-based Services (HCBS) services. See 5038 Waiting List Management and Criteria for Admission to Services. If client is determined to meet high priority targeting criteria, the following additional assessments must be completed for Tier 1 waiting list placement:
    
    The Determination of Need–Revised (DON-R) to determine level of functional impairment and unmet need for care in activities of daily living and instrumental activities of daily living. Refer to Chapter 114 Client Assessments in non-Medicaid Home and Community Based Services manual.
    
    For individuals requesting nutrition services only:
    
    The Nutrition Screening Initiative “DETERMINE” (NSI-D) Checklist to assess applicants’ potential for nutritional risk and need for further assessment and nutrition interventions. Refer to Chapter 114 for the NSI-D Checklist and instructions on its use.
    
    Staff shall use the Food Security Survey to assess applicants’ food security.
    
    Staff will use the HCBS Income Worksheet assessment to determine and discuss any non-Medicaid cost share obligations for services for clients being placed on a Tier 1 Waiting List.
    
    Caregivers being assessed for services only require a Bakas Caregiver Outcomes Scale (BCOS) assessment. Triage and other care receiver assessments are not required.
    
    Staff will use DAS Data System to assess and record applicants’ assessment scores.
  2. See 5038 Waiting List Management and Criteria for Admission to Services for reassessment guidelines.
  3. Interim Assistance: Staff shall make reasonable efforts to identify other appropriate community resources for persons placed on waiting lists. Staff will provide information to applicants about their option to pay the full cost of the service for immediate admission.
  4. Notifications: Staff will notify applicants for AAA-funded services of their eligibility or ineligibility for service, placement on waiting lists, or other disposition, by sending or providing a completed Applicant Notification form upon completing the initial assessments. See 5070 for a copy of the form (English & Spanish).
2. Duration of Information and Assistance: Information and Assistance (I & A) is a social service intervention, generally of a limited duration, during which any number of contacts with and on behalf of consumers may occur, over a limited period of time. Generally, the parameter for the duration of the involvement of primary I&A staff in the intervention is thirty days. If consumers’ situations require considerably longer to address or resolve, the Area Agency shall make provision for case management or community options counseling assistance to be provided at either the Area Agency level or by a care coordination agency. See § 210 Case Management Service Requirements.

1. Advocacy in the sense used in this policy does not include legislative advocacy or lobbying.