5036 Minimum Data Set Section Q (MDSQ) Options Counseling | 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:

Minimum Data Set Section Q (MDSQ) Options Counseling

Reviewed or Updated in:

MT 2020-01

Section Number:

5036

Previous Update:

Summary

This chapter establishes the requirements to be followed when Area Agencies on Aging (AAA) directly provide or contract for the delivery of MDSQ Options Counseling.

Scope

Aging and Disability Resource Connections (ADRCs), designated as the local contact agencies (LCA) for Minimum Data Set Section Q (MDSQ) referrals from skilled nursing facilities, will respond to MDSQ referrals by providing individuals, families, and caregivers information about community living services and supports.

Definitions

Action Plan: a plan outlining the steps identified in the options counseling process that are needed by the individual and/or options counselor to attain the supports that meet the goals and preferences of the individual. This plan is time bound and is directed and developed by the individual with support from the options counselor as needed.
Decision Support: a process of examining the pros and cons of various options. It may include information and education but goes beyond both of these both to support an individual as he/she weighs options.
Dignity of Risk: refers to respecting each individual’s autonomy and self-determination to make choices for him or herself. The concept means that all adults have the right to make their own choices about their health and care, even if healthcare and other professionals believe these choices endanger the person’s health or longevity.
MDS 3.0: Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes. MDS 3.0 has been designed to improve reliability, accuracy, and usefulness of the MDS, to include the resident in the assessment process, and to use standard protocols.
Motivational Interviewing: is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.
Options Counseling (OC): an independent decision-support process whereby individuals, families, and caregivers are supported in their deliberations to determine care choices based on the individual’s needs, strengths, preferences, values, and individual circumstances.
Person-Centered Planning (PCP): a process to develop an individual support plan that is driven by an individual’s own preferences, strengths, and personal goals, as well as directed by the individual and/or their representative.

Core Components

The core components of Options Counseling are:

Personal Interview
Assisting with identification of available choices
Facilitating the decision-support process
Assisting in the development of an action plan
Connecting to service
Follow-up

Goals of Options Counseling

The goals of MDSQ Options Counseling are:

To provide individuals with the information he or she needs to make informed choices about returning to the community
To provide appropriate guidance to proactively match individual’s needs, strengths, preferences, and values with available services
To help individuals plan for the future and avoid crisis planning
To help improve the quality of life of individuals receiving Long-Term Services and Supports

Staffing

Area Agencies will identify, at a minimum, one Full Time Equivalent to conduct MDSQ options counseling. See Manual 5200, 5027 Staffing for minimum education and experience requirements and equivalencies.

MDSQ Options Counseling staff will:

Utilize a person-centered approach in providing options counseling services to individuals identified on the MDS assessment as wanting to speak with the LCA about community living options.
Be supervised by the ADRC Program Manager or by another staff person who supervises the ADRC Program Manager.
Become AIRS certified when eligible. This is based on the AIRS criteria. AIRS certification shall be completed within eighteen months of employment as an options counselor.
Attend all training events required by DAS.
Become certified in Options Counseling through DAS. New staff shall enroll in the next available class after employment as an options counselor .and successfully pass all components of certification.

Options Counseling Activities and Standards of Promptness

At a minimum, MDSQ options counselors will perform the following activities:

Handle referrals in order of receipt.
Make initial telephone contact or contact attempt within one business day with identified individual to schedule an appointment to conduct a face-to-face options counseling session.
Conduct face-to-face options counseling session with individual within ten business days of receiving referral. This may include persons the individual has identified as wanting to be present during the face-to-face options counseling meeting.
An MDSQ Options counseling referral that requires one telephone call only will be entered in to the DAS Data System as I&R.
If APS involvement is identified, the OC will follow up with the APS investigator to avoid a potential transition back into a previously dangerous environment.
During face-to-face options counseling session and all follow up, options counselors will use a person-centered approach to explore options for the individual based upon their needs, strengths, preferences, and values. Options explored will be:
1. Accurate – options counselors will ensure information is to the best of their knowledge, up to date, and complete in nature.
2. Timely – information will be provided to individuals in a manner consistent with ADRC Standards of Promptness.
3. Culturally Appropriate – individuals and the system respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each.
4. Useful and helpful-options counselors will be mindful of options that could possibly be of benefit to the individual based upon their needs, strengths, preferences, and values. Options counselors will be careful not to overwhelm a person with options for which they would not qualify or that would fail to meet a self-identified need.
5. Complete – options counselors will explore public and private pay options with individual based on individual’s identified needs, strengths, preferences, and values. Options counselors will help individuals explore the pros and cons of options in assisting the individual in making an informed decision.
Information provided will be given in a language appropriate to the individual’s comprehension level. Options counselors will be mindful of professional jargon and minute details that can overwhelm an individual.
Provide a minimum of three follow ups to individuals who are not immediately referred to MFP, unless fewer follow ups are requested by the participant. The dates will be based on the individual’s need and preference. If three follow up contacts are not provided, the reason must be noted in the DAS data system.
Establish collaborative working relationships with skilled nursing facility staff including social workers and discharge staff.
Complete and enter into the DAS Data System all required documentation for individuals who receive MDSQ Options Counseling within five (5) business days of options counseling activities.
1. Required documentation:
  1. Nursing Home Transition Screening Form
  2. DON-R (required for MFP Eligible individuals)
  3. Action Plan (Appendix 5060 – F)
  4. Case Notes and follow up
  5. Risk Assessment Tool (required for NHT Eligible individuals
  6. Additional documentation as needed
If an individual qualifies for the Money Follows the Person Program (MFP) the options counselor will refer the case to the Transition Coordinator (TC) within five (5) business days using the following process:
1. Individuals who are eligible for MFP will be referred to either the Center for Independent Living (CIL) or the AAA using a rotation method between organizations when both areas serve the same geographic area. If the CIL does not serve the area, the referral will remain with the AAA.
2. If the AAA and the CIL develop an alternate arrangement for referrals that is satisfactory to both parties the AAA will submit this process in writing to the DAS Transitions Specialist for approval. If approved, this alternate method may be used.
3. If the individual is then deemed ineligible for the MFP program, the TC will refer the case back to the MDSQ options counselor for continued follow-up and exploration of public and private pay options to assist the individual in transitioning into the community.
4. If an individual is deemed eligible for MFP the MDSQ Options Counselor will submit a waiver application on behalf of the individual, but a waiver is not required prior to the referral.
5. Housing options and applications must be reviewed prior to referral to Money Follows the Person (MFP) Transition Coordinator, but housing does not have to be finalized.
6. If the MFP TC is also the Nursing Home Transitions (NHT) TC, the case does not have to be referred back to the MDSQ options counselor for continued follow-up.
If an individual qualifies for the Nursing Home Transition Program (NHT), the options counselor will refer the case to the NHT Transition Coordinator (TC) within five (5) business days using the following process:
1. Individuals who are eligible for NHT and are 66 years old and older will be referred to the Transitions Individuals who are eligible for NHT and are 66 years old and older will be referred to the Transitions Specialist at the AAA.
2. Individuals who are eligible for NHT and are 65 years old and younger will be referred to the Center for Independent Living. The CIL retains the right to refuse the referral if the distance presents a hardship due to designated service area.
3. If the individual is deemed ineligible for both programs, the TC will refer back to the MDSQ options counselor for continued follow-up and exploration of public and private pay options to assist the individual in transitioning into the community.
All referrals will be documented in the DAS Data System by using the Provider enrollment and Alert Note to the receiving Transition agency. If the CIL is unable to transition an individual, they should also return the referral to the MDSQ Options Counselor via Alert Notes documenting the reason for their inability to accept the transition. If a referral is not accepted by the CIL and/or the alert note remains unread, the MDSQ options counselor can take the referral back after 5 days to be rebrokered to another Transition Coordination agency. The OC must note the reason for rebrokering in the DAS Data System.
If necessary, DAS may re-designate staff to assist in other areas or with other roles relating to options counseling and transition services.
The organization providing the delivery of MDSQ Options Counseling is required to establish a formal referral process to all organizations within the service area who provide MFP and/or NHT Transition Coordination.

Short Term Rehabilitation Referrals

Referrals from individuals who are receiving short-term rehabilitation services:

If an individual has a discharge plan/date, the ADRC can choose to have the options counselor:
1. Send a community resource packet to the individual at their home address omitting a visit to the facility. This will be entered as Information & Assistance Type of Case, not options counseling in the DAS Data System, or
2. Provide nursing homes and other institutions information packets for distribution to individuals admitted to the nursing facility for short-term rehabilitation who answer ‘yes’ on Section Q questions and MDSQ referrals made.
All MDSQ referrals received at the ADRC will be entered into the DAS Data System as directed in the ADRC standards.

Additional follow-up for individuals for short term rehabilitation is not required, unless in the professional opinion of the MDSQ options counselor it is determined that additional follow-up is needed or the individual requests follow-up appointments involving a referral to either MFP or NHT.

The Action Plan

The action plan is required in all options counseling. The action plan incorporates the next steps to be completed by the individual as well as the next steps to be completed by the options counselor. A written copy of the action plan will be left with the individual and will include follow-up date and contact information for the Options Counselor. The action plan will be entered into the DAS Data System. See Appendix 5060-F.

MDSQ Options Counseling in MFP Transitions

MDSQ options counselors may take responsibility for MFP transitions consisting of, with approval from the TC or TC Supervisor:

Transition to Personal Care Home
Transition home with family or other member of support circle (no major conflict noted), can include family legal guardians in agreement with transition
The MDSQ options counselor must follow all MFP program guidelines, including documentation. After 90 days, the options counselor may transfer the individual to the TC for monthly follow up calls.

MDSQ options counselors will not take responsibility for transitions consisting of:

Area to area transitions
Independent living transitions
DHS wards

Client Records

MDSQ options counselors will enter MDSQ referral client information in the DAS Data System using established procedure. Basic client information will be entered within one business day of referral receipt. Detailed information and information from activities will be entered into case notes within 3 business days of completion of tasks. All data will be entered by the 3rd of the month following the month the referral was received to coincide with submission of the MDSQ monthly report.
MDSQ options counselors will enter case notes identifying activities conducted and description of individual’s self-identified needs, the options discussed, and the action plan.
The MDSQ monthly Outreach Report is due the 3rd of each month. Must be submitted on the form provided by DAS.
Each ADRC Program Manager will develop and implement a quality assurance process to review data entry and documentation for options counseling.
MFP field personnel (OCs and TCs) are responsible for the following regarding MFP denial and terminations: issue denial notices to participants including administrative hearing rights available for denial of eligibility or termination of service. Maintain appropriate documentation of decision-making for administrative review and appeal See Department of Community Healthy Policy 605.5.
Options counselors will provide individuals with a copy of the booklet, HCBS, A Guide to Medicaid Waivers in Georgia. Requests for booklets can be faxed directly to Georgia Health Partnership (GHP) using the request form (DMA 292 – Request for Forms or Handbooks). See Appendix 5060-J.

Outreach

MDSQ options counselors will provide outreach to all potential sources of referrals to MFP, NHT, and ADRCs to include skilled nursing facilities, hospitals, and other community organizations. Outreach must be completed in a face-to-face setting and includes, but is not limited to presentations, community education events, and resident council meetings. With prior approval from DAS, non-face-to-face outreach can be counted towards the minimum monthly requirement. Outreach must include the provision of information related to transitions and community options. Meetings with nursing home social workers may be considered outreach when the social worker is new or is unfamiliar with options counseling and transition services.
MDSQ options counselors will complete a minimum of four outreach events per month and record outreach events in the approved DAS Data System. Outreach activities will be reported to DAS, using the required form, by the 3rd of each month.
MDSQ outreach events will be entered into the DAS Data System (DDS) within three (3) calendar days of the event date.
MDSQ options counselors will serve as active members of the ADRC Advisory Council in their region.
MDSQ options counselors will provide skilled nursing facilities with copies of the MDSQ referral forms, using those provided by DAS or those provided by the AAA, using the ADRC logo.
MDSQ options counselors will try to provide outreach/education to each nursing home’s Resident Council members or Council President at least one time annually to explain transitions and options counseling services.
1. The request for an invitation to present at a meeting shall go to the Resident Council President, or, in the absence of a resident serving as President, to the designated nursing home staff.
2. In the event the request is refused, the MDSQ OC will request assistance from the Long-Term Care Ombudsman serving the facility residents. Presentation at a Resident Council meeting counts as one outreach event.
3. This requirement may be satisfied by meeting with the President of the Council, explaining the service and leaving contact information.

Mandatory Reporting

All staff must be familiar with and able to recognize situations of possible abuse, neglect, or exploitation or likelihood of serious physical harm to persons receiving services. Providers shall develop procedures for reporting suspected abuse, neglect, or exploitation.

Suspected cases of abuse, neglect and/or exploitation of older adults and adults age 18 and older with a disability residing in a long-term care facility, are to be referred to the Department of Community Health, Healthcare Facility Regulation by contacting 800.878.6442 or visiting dch.georgia.gov.

References

DAS Manual 5200, Section 5027
DAS Manual 5200, Section 5060-B
DAS Manual 5200, Section 5060-F
DAS Manual 5200, Section 5060-J
DAS Manual 5200, Section 5060-K
DAS Manual 5600, Section 2025-2028
Department of Community Healthy Policy 605