5037 Community Options Counseling

Georgia State Seal

Georgia Division of Aging Services
Access to Services Manual

Chapter:

5000 Aging and Disability Resource Connection (ADRC)

Effective Date:

Section Title:

Community Options Counseling

Reviewed or Updated in:

MT 2019-01

Section Number:

5037

Previous Update:

Summary Statement

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

Scope

Options counseling supports informed decision-making about Long-Term Services and Supports (LTSS) and represents a core function of Aging and Disability Resource Connection (ADRC). Many individuals need options counseling for the following reasons:

  1. An abundance of information is available about LTSS but the information can be complex, contradictory, and confusing

  2. Individuals and/or families may want or need additional support interpreting information and weighing the pros and cons of their different options related to LTSS

  3. Few people plan ahead for LTSS needs institutional placement often occurs without consideration of available community-based options

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.

Caregiver

a family member, partner, friend, or neighbor who supports an individual. Caregivers may also be the individual seeking options counseling for their own support needs.

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 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.

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, preferences, values, and individual circumstances.

Person-Centered Planning

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:

  1. Personal interview

  2. Assisting with identification of available choices

  3. Facilitating the decision-support process

  4. Assisting in the development of an action plan

  5. Connecting to service

  6. Follow-up

Eligibility

Options counseling will be available to anyone contacting the ADRC. Situations and triggers that may indicate the need for options counseling include:

  1. Individual requests information or advice concerning LTSS

  2. Individual is referred to ADRC through a critical pathway provider (hospital, assisted living, or other agencies)

  3. Individual has had a recent significant change in life situation and is looking for assistance

  4. Individual has LTSS needs, but is unsure on how to access services or what services may be available to best meet their needs and preferences

  5. Individual is requesting assistance transferring from one living situation to another

  6. Individual might be eligible for new benefits and is unsure what will best meet his/her needs and what he/she may be eligible for

  7. Individual is interested in consumer-directed service options

  8. Individual has been admitted to a hospital and needs help planning once discharged

  9. Individual lacks awareness of potential LTSS options for remaining in the community

  10. individual has multiple needs across many services or systems

  11. Individual has been denied Medicaid and needs decision support around non-Medicaid options

  12. Individual is at a Risk Level 2 as indicated by the Risk Assessment Tool

  13. Individual does not meet qualifications for wait list placement but is in need

Staffing

Area Agencies will identify, at a minimum, one FTE to conduct community options counseling. Minimum education and experience requirements and equivalencies are located in MAN 5200, Section 5027.

Options counseling is, to the extent possible, provided by one options counselor who supports the individual through the entire decision-making process and follows-up with the individual during scheduled follow-up contacts.

ADRCs can choose to have specific staff designated as options counselors and options counseling is their primary job responsibility or to organize their staff with blended roles based on organizational capacity. Options counselors will be supervised by the ADRC Program Manager.

Options Counseling Activities

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

  1. Deliver options counseling in the setting and by the method desired by the individual, resources permitting. Settings may include: over the phone, individual’s place of residence, hospital, medical practice, Agency, etc.

  2. Provide options counseling in a manner without personal bias of the options counselor and without a vested interest in the decisions made by the individual.

  3. Include discussion of publicly and privately funded LTSS.

  4. Assist in making appropriate connections to services (i.e. SHIP, financial, employment, mobility assistance, peer support).

  5. Facilitate future planning by talking with individuals about options for services and supports that might be needed in the future.

  6. Provide decision support. Assist individuals in evaluating various pathways, including the pros/cons of specific options of interest to the individual.

  7. Relay information with language appropriate to an individual’s comprehension level, being mindful of professional jargon and minute details that can overwhelm and confuse an individual.

  8. Provide connections to community supports that provide or coordinate eligibility determination.

  9. Complete a written action plan with individuals during the options counseling session.

  10. Provide follow up 30 days after completion of action plan if applicable or, 30 days after completion of options counseling session, or when indicated by the action plan.

Action Plan

The action plan is required in all options counseling. If an action is not completed, the session is entered into the DAS Data System as Information & Assistance only. 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 the follow-up date to be as agreed upon by the individual and options counselor and the options counselor’s contact information. If options counseling is being completed via the telephone, a copy of the action plan can be mailed, emailed, or faxed to the client. The action plan will be entered into the DAS Data System. Refer to Appendix 5060-F.

Follow Up

The 30 day follow up has the goals of:

  1. Clarifying questions and or concerns of the individual

  2. Providing assistance regarding applications and eligibility process, if requested

  3. Providing assistance regarding implementation of LTSS

  4. Evaluating the usefulness of the options counseling service and identifying barriers encountered in assisting an individual in achieving his or her goals

Staff Training

All persons performing options counseling will receive initial training. Each ADRC will have staff development program in place including the following areas:

  1. Physical and emotional aspects of aging and disability

  2. Understanding the dignity of risk and an individual’s right to fail

  3. Decision support strategies (person-centered planning, motivational interviewing, etc.)

  4. Communication techniques, including the use of adaptive and interpretive communication devices

  5. Cultural competence

  6. Information and resource program, both publicly and privately funded

  7. Documentation and follow-up protocol

Partnerships

Options counseling is at the center of streamlined eligibility, a core component of a fully-functioning No Wrong Door. Partnerships are the foundation of this component and must include key partners in the process, including, but not limited to, the following:

  1. State and local representatives of the aging network

  2. State and local representatives of the disability network

  3. State and local representatives of the Medicaid agency

  4. SHIP representatives

  5. State and local providers for other long-term services and supports programs

Client Records

Options counselors will enter client information into the approved DAS data system. Case notes will be entered under Formal Case Notes in the data system following DAS policy on case note entry located in MAN 5020 Appendix I. This will include a completed action plan created by the individual with the assistance of the options counselor.

Fee for Service

Each AAA/provider is encouraged to offer options counseling services as a fee for-service enterprise to enhance the sustainability of the Aging network. The AAA must follow all requirements of MAN 5600, Sections 2025-2028.

Mandatory Reporting

All staff must be familiar with and be 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 community dwelling adults, age 18 and above, are to be referred to the Division’s Adult Protective Services Centralized Intake (1-866-552-4464). A voicemail may be left after hours. Alternatively, a fax referral form and instructions and a web reporting form are available on DAS’s web page, aging.georgia.gov/.

Any situations in which abuse of minor child/children is suspected are to be reported to the appropriate County Department of Family and Children services (DFCS) at 1-855-GACHILD.

References

DAS Manual 5200, Section 5027
DAS Manual 5200, Section 5060, Appendix F
DAS Manual 5200, Section 5060, Appendix I
DAS Manual 5600, Section 2025-2028