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Informing Long Term Care Choice – MDS 3.0 Section Q Training – Recurring Themes and Next Steps


MDS Module 3.0 Review [Bob Mollica] Each of the sessions had a recorder, and we’re going to turn to those folks to present what they observed as the recurring themes in each of the three concurrent sessions. And then we’ll have some opportunity to ask questions and to identify things that you think need to be addressed. We’re looking to develop ideas, suggestions for the conference call to make sure that it reflects the most pressing issues on your mind. You will have an opportunity to send emails to folks, and, as you’ve thought about them on the way home, but while they’re fresh, if you have some ideas, that would be greatly appreciated. And then we’ll finish with brief discussion of the next steps. And we’re going to turn to Mary Beth, Sarah, and Bob to give their thoughts on what the recurring themes were. [Sarah Fogler] I can start because [inaudible] the first — okay, I’m going — can everyone hear me okay in the back? No. Okay, good thing I asked. Okay, good now? I was the recorder for developing an implementation strategy for each of the states. And in this session, we talked about topics like setting up a state system, what the different roles of folks who would be involved in this system would look like, how we would coordinate roles and overcome barriers, et cetera. And some of the recurring themes that I just wanted to touch on in that session were — really involved around education, communication with your partners, and collaboration. Mainly, some of the things that came out of those sessions was stakeholder involvement, developing all of your policies and procedures, so maybe starting with like a retreat, I think, came up, establishing a work group came up, having pretty regular meetings initially, and then maybe weaning off a little bit as your implementation strategy got fleshed out a little bit better. Some other things that came out in terms of outreach and education was a key step in the startup is developing a marketing and outreach strategy to collect some of your partnering organizations, so folks that would be included in that would be local contact agencies, like your ADRCs — excuse me — your SILS, any other contracted agencies that you’re hoping to work with to transition folks out based on Section Q outcomes. A lot of people talked about products they had developed, tools for education, for example, with the nursing home staff, educating them about Section Q, what resources were available, also educating the local contact agencies, which I thought was neat, too, updating those folks on what programs are available within the state, because as folks know in here, we tend to be siloed in some of our programs, so educating one another on what you have available in your specific programs so that the folks working with people in nursing homes have a wide breadth of knowledge about what’s available to them in the community. Some other themes that came up were leveraging resources; that can be anything from staff time, adding certain elements to data tracking systems to help identify folks for transition and then follow up with them once they actually have transitioned, so leveraging resources — let’s see, what else did I have here? Another, I think, important point that came up was be clear on who you’re targeting. Certainly, you’re going to have to prioritize within the states as, you know, resources become more and more available, you’ll be able to expand your priority targeting, but, initially at least, know who you’re aiming to help transition out first. So, just to summarize kind of the three initial steps for developing an implementation strategy from your peers, what came out was to first determine a stakeholder group. Who are your partners? Maybe schedule a retreat with these folks, or establish a work group within your state. The second thing to do is to develop a marketing and outreach plan to promote the program, educate folks on the new Section Q and what partnering activities are expected or anticipated. And then the third thing is to offer formal training opportunities to nursing homes, local contact agencies, et cetera. [Bob Connolly] Okay, my name is Bob Connolly, and it’s a special week I’ve had because for 10 of my last 19 years at CMS, I was the project officer for the MDS 3.0. And from day one, they said, “It’ll never happen, Bob,” so… [laughter] I’m here to tell you it did. So, I am a consultant now, and as a social worker by training, this is just so great to have gone from public policy and medical care and pressure ulcers and depression to now looking at return to community and working with Mary Beth and John and Dan and the rest of the team is great. So, our group was around collaboration and partnership, and it kind of — the themes kind of fell out into first what you do as a state. So strategic leadership, planning, visioning, what’s your overarching vision, how do you bring systems change to people to work with your aging population is kind of the first major theme. The second is how do you find key people and champions within your state, within your facilities to work with. And then, what Rowann [spelled phonetically] kept saying is how do you keep the facilities informed during the process but after, and how do you bring some transitions residents back. The next area was really the more management of patient. How do you identify your resident? What mechanisms do you use? How do you address complex patients? How do you deal in and look at risk management and sometimes fail in risk management but always learn from it and take that back to the next phase? The other is your — the roles of nursing home and the contact agency — how do you define them? What tools can you use, and there are some tools, and how do you be flexible, because sometimes they need help? Then we moved into what you’re doing really impacts the business of a nursing home and may decrease their volumes. So how do you deal with the south interest of the nursing home administrator and their staff to bottom line? How do you deal with the manpower, who, if less patients are there, would have to deal with it? And there were some exciting strategies of — one state said we were not saying we’re reducing patients; we’re just recycling patients in quicker, because with the baby boomers, there’s going to continue to be the volume. Another state really looked at manpower. How do you kind of help that manpower get trained to do more community work? Then the last thing was really culture change and how do you bring this new culture, that community living — all staff want what’s best for the resident, and how do you move that forward? And then what are new business models that nursing homes must adapt to survive? They can’t be in — they may be in this only to save a building, but in the long run, it really is a different market that they have to address. And then there were a couple of things that I thought that were great recommendations to CMS nationally. One was we talked about success stories. There was a front-page newspaper article in Connecticut with all the nursing home residents seeing a patient that they never thought could go, going home. And how do we take that success story or other success stories and put them into video so that other states can kind of say, “Really, this stuff works, and it really does make people feel good.” The word that kept coming up again and again: how do you educate, educate social workers, educate discharge planners in hospitals, educate nurse DONs and administrator, how do you work to educate families, how do you keep going back to your existing networks, giving them updates that we’re now doing this, so that they’re aware of it? Then, the other thing, being a former CMS staff, is CMS can’t provide all the answers. You’re doing it. You have the answers. One idea was become an idea generator and an out-of-the-box thinker in a non-policy way to help develop models of care and help push for services that aren’t there. Clearly, they’re not services — they are from ill health and homelessness at the level they need to be there. So if you push that and you create models, then you create best practices, then that can be sent up to the national level. Educate your state. Educate CMS with what you learn. They’re or we’re in office and cubes, but we care tremendously, but we don’t always know what you’re doing. And then set a strategic vision for your state. That kept coming up again and again. So thank you. [Mary Beth Ribar] Okay, hi everybody. Oh, is this on? Hello? Yeah, okay. Ours was creating successful outcomes for referrals, and we had four people talk. The first one was the ombudsman program and the National Citizens Coalition. And a real good overview was given on what does [unintelligible] do at the national level versus what can your local ombudsman do? The takeaway message for me as I listened to Laurie and Beth talk was involve your ombudsman. Involve him early on. Involve him in the planning meeting with the resident in the nursing home. Use them as the consumer advocate. They can follow that individual out into the community. They can provide assistance to the transition agency and the nursing home. Some states are contracting with the ombudsman program like Ohio does. You could have a contract with the ombudsman program and give them money to do some things for you. So the big takeaway message was just, you know, really use them. They are a consumer advocate. They can build on lessons learned. They can make connections. They can report back to you what’s going on with that person. And so, in many states, it’s a very untapped resource. And it’s an important one and one that can be used very effectively. Okay, so that was the takeaway message from the first portion of our session. The second one was Pennsylvania talking about housing. The big takeaway message for this was, “Do it on all levels, in all layers, with everybody,” okay. Connect social service with housing — local, state, and federal. Pennsylvania is a very good example of — they’re going down every avenue there is. So in your state, find out all the avenues. There’s tax credits. You can work with private developers. You can get on the preference list for the — you know, the FHAs and the Public Housing Authorities. A lot of states, or most places, you know, these big states — you can’t do one thing for all of them. You have to talk to each individual local housing person, entity, getting their planning stuff, getting their faith; educate each other; learn each other’s language. And Pennsylvania has worked long and hard to do this, and like Jen was talking about , all layers, all levels; everybody, empower your staff; learn the language, educate them; and just keep plugging away at it. And it takes time to make those in-roads, but you’re going to have a big, big payoff for you. Okay, the third state that talked was Texas, and you’ve heard from Mark. And Mark is great because he’s so enthusiastic. I love to hear Mark talk. But the big words that he used over and over again were collaborate, communicate, and coordinate. He brought up the two major issues for transition, of course, that you heard at lunchtime, people with substance abuse issues, behavioral health issues, mental illness issues, and housing, same thing. He said you got to talk to everyone in your state that touches these people. Get your — they had a big meeting — get your mental health agency; get your behavioral health agency; get your long-term care division or whatever it is; get your housing people; get everyone together and start to develop the plan and program. And they came up with two really good strategies. They had two programs. They had cognitive adaptive training and also the substance abuse program. I actually heard Mark do his presentation for one of our technical assistance calls. One of the things that I learned from that call, which I think was critical, is you don’t wait until the person moves out with any of this. That person with these long, life-long standing issues that are ingrained and learned, they have to unlearn and learn a new way. You work with them six months before they walk out that door. You take them out to NA program. You take them out to their person they’re going to see as a counselor. You bring people in to them. The person who needs help with figuring how to, when I get up, “Oh, these are daytime clothes, and these are nighttime clothes.” You start doing it in the nursing facility. They get used to the system. They know how to do it. So then these people, when they get out, they’re successful. They’ve learned the behaviors to becoming successful. So they’re just, you know, it’s just another day. Now they’re out there doing the same thing they were doing where they were living before, but they have the tools to do it. So just an excellent, excellent example of, again, collaborate, coordinate, and communicate. Everyone has to talk. You have to have a common goal. You have to develop your strategies and programs together. You have to implement and look at it together, see how it’s working, and keep checking back. Really, really a wonderful success story. Our final theme was Minnesota, and we had talked about quality, same theme for me again, all layers, timely, ongoing, monitoring. You have to address all the things related to quality. Of course, the usual things: health and safety, you know, are they getting the services they’re supposed to be getting? Their satisfaction, can they go where they want to go when they want to go? Do they have the supports they need? What is their quality of life like? What Wisconsin has done is they do a 30 and a 90-day survey to see how these people are doing. So, again, they don’t wait six months; it’s too long. These people are going to be back in the institution. So you have to build in very critical time periods of when do we need to touch base, face to face with that person and the case manager? And, again, a really good example of doing this well — get in there early; get in there often; look at what you’re getting. They learned a lot from what they’ve been doing. They figured out, even when they — after doing all this monitoring, and their surveys and their on-site visits, they’ve built all that in. Then they looked at what they did and why these certain things were happening. A certain percentage of people, as they talked about earlier, I think, you know, after they moved into the community, they died or passed away. It was anticipated. Those people wanted to go home, be able to be at home before they died. So, again, the takeaway message for that was, “Early, often, ongoing, keep at it, and learn from what’s going on,” in a continuous loop like we always talk about, with a 1915(c) waive of requirements for quality. But, again, they’ve done a very nice job of doing it in multiple layers, cross — you know, their populations for the 1915(c) waiver, and learning from what they’re doing. So, really good job for all the sessions, and we really thank all the presenters and the participation. I felt like that’s very beneficial to really get not only some good examples, but some really key takeaway messages and strategies and things to start with as you guys go back to your states. But thank you everybody. [applause] [Bob Mollica] Okay, now it’s your turn: questions you have of going forward, suggestions for what to do, what to cover on the training call, any one of the three. Oh, there’s one in the back. [Female Speaker] All right, I’ll just say what I saw at every confidence, which I think needs to be said again. And that is, just remember that assisted living is going to be our biggest policy issue at the national level in the future. I was just looking at a PowerPoint from the conference on long-term care partnership that was held recently — I think it was down in New Orleans. And we sent someone from our department of Commerce there. And she came back with a PowerPoint where — now, those folks were sitting around talking about claims for long term care insurance, and they were specifically looking at assisted living. And there are two really key slides in this PowerPoint. If anybody wants it, shoot me an email, but one of the things they were looking at is making sure that when people recover, that if they go into assisted living and recover, that they end their ability to claim. And they’re really in these two slides pointing out that assisted living — people are going in sooner, and they’re spending down faster. I know that, you know, in Minnesota, this is a major policy issue for us. And I was just hearing a lot of people say at this conference that we hope that there are more slots on the waivers for people going into assisted living, but we’re actually, in Minnesota, we’re looking at, “those are being reduced.” So that’s not a viable solution in the future, because it’s just going to really rebalance us in a different direction. So I just would point that out, curious what people thought. [Bob Mollica] Any other thoughts, comments? Yes. [Daniel Davis] Daniel Davis from HHS Office on Disability. Just wanted to ask, because one thing that was raised at the lunch discussion on the pilot was very striking, which was the sort of paired — the way that the questioning works if people have a discharge plan already in place, they’re not asked the question about transitioning, and I just wanted to get some thoughts as to sort of the challenges that that might — challenges and also potentially opportunities that that might raise. [Mary Beth Ribar] Yeah, thank you. I was surprised when I heard the findings at lunchtime. And so this is a very good example of something we have to look at and see exactly what is the deal here, and do we need to refine it. So, of course, when you do anything like this, like I said this morning, we had a lot of people kind of working through this, and does it make sense, and we want to make it practical, but we want to make sure we ask people the question, and referrals are done, but they’re not done in an ineffective way and, you know, the whole gamut. This is where I’d like to hear from, or we’d like to hear from you guys via the MDS for Medicaid email address. What we’re thinking of maybe pooling a small group of nursing home folks and some others together and actually — people actually would, like, ask these questions and walk through them, and, again, think through it and say, “Does this skip pattern [spelled phonetically] make sense or do we need to tweak it some?” So thank you for that question, because we don’t want to lose it. So send in your suggestions, or if you think that’s a good idea, to pool a small together, kind of look at the skip patterns for this and see, does it make sense, is it getting us where we need to get to, are there issues with it, is there something we need to fix before we get to October, okay. So now’s the time. We can look at it and see what we can do, okay. [Bob Mollica] Liz? [Female Speaker] Thanks. This is just a cautionary note. You know, Washington, we already have a good transition system in place, and getting that coordination between the nursing facility and the person handling the transition is already there. However, even with our own self-imposed timeframes on getting back to people within that system, we’re already behind on what we would like to be seeing in terms of our ability to go in and do these assessments. So I know you all know that states are hurting because of freezes and cuts. We don’t have the same numbers of staff we used to have, and the system is overloaded. So I know that there aren’t any penalties being talked about right now for not meeting timeframes, but I just wanted to make a note that it’s going to be hard even for those of us who have the systems in place. And our intentions are good, and I appreciate the idea behind having this in there, but it is going to be a difficult thing to meet those 10-day timeframes. [Mary Beth Ribar] Thank you. And as Melissa said this morning, we know the resource issue is a big one. I don’t know if everyone — I haven’t read the whole health care reform bill, but they did extend the Money Follows the Person Program, and they doubled the funding. So there’ll be opportunities for states to get into that and have funding to actually do this work, also, through the ADRC grants and the MFP grants. Again, many of you already know this, we’ve opened up the opportunity for more administrative money to actually assist states to do this work. So we hear you. We’re working on it. You as states need to take advantage of the opportunities as they come up. So just keep listening — you know, keep looking because other things will be coming through as a result of the health care reform with some assistance to states in the way of funding and mechanisms to use that for transition work. [Bob Mollica] I saw another hand. Oh you have — [Female Speaker] I just wanted also to touch on the skip pattern that when the discharge plan is in place that the questions are no longer asked. I think that we all agree there are additional pieces that people need to be successful when they return home beyond the discharge plan provided by the nursing home, home modification possibilities, future planning, those sorts of things that a local agency like an aging and disability resource center would provide to somebody to help them be successful, and that piece would be missed if that question is skipped because there is a discharge plan in place. [Mary Beth Ribar] Good point, and Sarah was going to say something — [Sarah Fogler] I can’t resist, I have to because I used to, actually, do discharge planning in the nursing home. So I have to say this as a caution, too. This speaks to the importance of collaborating and educating one another when you’re working with nursing facilities because their definition of discharge planning is potentially very different from how we are framing transition planning. So I think we are all very aware of kind of the challenges with that skip pattern. That’s something we’ll look at, but I think there’s an additional component of that that speaks to kind of where you need to have the same language — [Bob Connolly] And this is Bob. As Melissa’s slide says, this is a paradigm shift, and I’ve actually participated in an administrator and social work focus group with Sarah and a couple of other colleagues. And one of the most powerful moments on that call was was a social worker had said that — well, some of the administrators and social workers said, “We can’t think of anybody in our building,” which is really hard to hear, but might be where the change has to come. And then one of the social workers said, “My mother was in a nursing home, and I didn’t want her to go home because she might fall and all the risk, but the staff actually helped me to understand.” So the nursing home can give you help to do better community work by having their nurse practitioners and all the medical and support staff. [Female Speaker] I just wanted to comment a little bit, particularly around those questions that we were talking about, the discharge plan and the option of discharge to community determined to be not feasible. I’m worried that that might knock some people out of the box before they even get the chance to get some information, although you certainly don’t want to give people false hope. You also want to make sure that the discharge planners are aware of what’s out there and what’s available before they make the determination that something isn’t feasible. [Mary Beth Ribar] Yeah, we’re worried about that, too. [John Sorensen] And when is that going to be re-determined, re-evaluated. [Mary Beth Ribar] Right. What John? [John Sorensen] And when will that be re-evaluated? [Mary Beth Ribar] What about that phrase, feasible? [John Sorensen] How long are we — how long is discharge determined to be not feasible. [Mary Beth Ribar] That’s why we left it quarterly, so the next opportunity comes up quickly. Okay, it’s not a whole year before you revisit this. So we were trying to — you know, like you say, walk the line between making sure that that choice and information and access to care and information was there, but be practical. If we didn’t reach the mark, tell us, okay. We want to hear from you. [Bob Mollica] Julia. [Female Speaker] Okay, two points if I may, and I want to reiterate, I really do think this is a good idea. For UCMS types up on the podium, state Medicaid agencies may well have been expected to do some variation of discharge planning with non-Medicaid folks since over ’87. But I know it certainly hasn’t occurred in my state, and I don’t think it’s occurred in many other states. In order to have contracts in place by October 1, we basically need to start figuring out what we’re doing Monday. We can’t figure out what we’re doing or contract till we understand the funding availability, cannot. That’s my point, number one. Point number two is particularly in low-occupancy nursing facility states like Oregon — you know, Jim Pazudi [spelled phonetically] said in an early conference, and it’s absolutely true, facility administrators, facility staff, they have mortgages and obligations just like the rest of us. We can try to be as collaborative as we possibly can, and we do try, but you’re attacking what they do for a living. So I’m really concerned about the skip patterns. I’m really concerned about who determines the feasibility. I’m really concerned that even with the best intentions the nursing home staff has no idea the resources that are available. And I’m done. [Mary Beth Ribar] Thank you. [Bob Mollica] Yes? [Female Speaker] I’ve been here all week at the SES [spelled phonetically] training. I listened to the Section Q the other day, and I never once heard distress that I got today. The people that are here from my state, we all just went, “What?” This is a whole different thought process then what we got on the MDS 3.0 Training this week. And you are right, Bob, that this — we’re not talking — this conference is not talking about discharge planning. You’re talking about transition planning. And from a nursing home perspective, and the people that work in a nursing home, I think we do — I think you all said that — do a good job of doing discharge planning. We discharge plan. We look at that process. We don’t look at transitioning, and I think all the statements that have been made about how concerning this is, that we have to be up and ready October 1, I think it is a real issue for a lot of states. I’m a state that’s got Money Follow the Person in it, and we’re hitting wall after wall because we don’t have people who can “transition out.” Now I’m wondering if we just don’t know where they can transition to, and so the facility is throwing up barriers to the whole process. And I feel like we’re coming late to the party. You know, I’m not dressed right, I’m in the wrong setting, whatever. And I’m looking at the fear of our facilities in our state of trying to get MDS 3.0 up and running effectively when we’ve been hearing that statement thrown at us since MDS 3.0 said it’s coming up October 1, it’s not being phased out, and now I’ve got a new issue, this transition planning issue, which we’re not disagreeing — I’m not disagreeing with the positiveness of it. I just think we’re looking at our facilities to take on two major loads in a very short amount of time. [Mary Beth Ribar] Yeah, and we hear you. I mean, I guess two things: one is — and you’re right, at the beginning of the week, John and I had an hour, and we could not go into the depth of discussion in the paradigm shift and everything that we went into today. That was the purpose for today. Also that nursing homes, as you said, you do your discharge planning. The local contact agency is the entity that does the transition planning. They’re your resource. Again, we’ve brought up, there’s a big resource issue around that we’re going to work out. The comment, and I totally hear you about coming late to the party, this is CMS’ effort to get the party started. It may seem late, but we’ve been working a whole year to even get here. So now between now and October 1 what can CMS offer in the way of coordination and support to states to get ready. We have — on May 12 we have a technical assistance teleconference set up already. Everyone has it in their book. Everyone signs so that you can participate. We want to hear from you. What is the priority for discussion for that call? And then what can CMS do to support states to get ready? So we will be working with you, and assist you, and support in the ways that we can between now and October 1 through technical assistance activities however we can do that. So, you know, we’re going to try to help you, but I don’t — the transition planning is a local contact agency. That’s their job; that’s what they do. Nursing homes do discharge planning. We don’t want to say that nursing homes have to go out and do fine tone [spelled phonetically] modifications and find housing and do electronic equipment and stuff. We don’t expect nursing homes to be doing that. [John Sorensen] I want to add a couple of things. And you know, Sarah Fogler is relatively new to our staff. She’s been with us for a year, but she kind of educated us on the role of the social worker in the nursing facility. She said, “You know, of course, we don’t discharge a lot of people because we don’t know how to find housing, but that was our job, too, and finding care services in the community, and we have a hundred people that we’re responsible for.” So with this local contact agency — we’re bringing in some support to help you with that, because we know that the social workers and the discharge coordinators, or whatever the title is in the facilities, have a heavy load. And this isn’t really — what you’re best at is not arranging community support services. To Julia, I want to say as far as the funding issue and to the comment about coming late to the party, first of all, we started developing Section Q a year and a half ago. And we sent an SND letter to your state Medicaid directors last October, if not before. We sent two, maybe three letters reminding them, “Okay, Q is coming. Get ready.” And so — well, tell me, how many people in the room, how many of your states have not made a move to put a local contact agency in place or begun communications? Okay, a few. But as far — okay, we started notifying some time ago, and so now we’re kind of goofing it a little bit because it’s getting close. But for the funding issue I’ll say that states with Money Follows the Person programs, I hope that you volunteered. You know, a lot of our NFP programs are up and running and are successful. Some are behind in their transition numbers, others are not. But if you know that your state now has a requirement to have a local contact agency available, I hope that you’ve offered your services. It’s — not in every state, but in most states, it’s part of the work that your AAA does; it’s part of the work that your ADRCs do. They have money for these things. Call them; start working with them; begin this collaboration. Remember earlier today, and then on Monday and on Tuesday, this is my job to hike the Kumbaya thing. Let’s all start working together, hold hands, and help each other get this job done. [Female Speaker] Yeah, I fortunately am an MFP state, so I feel comfortable with the Medicaid population, but the non-Medicaid is really throwing me as to where I’m going to find resources to actually perform transition activity and provide the services and the supports and — I mean, we’re spending a lot on the Medicaid. Like I mentioned earlier, when I was — I had talked to an individual at the University of Michigan Rehab Center and said, “Can we help them with ramps,” because he just — he doesn’t know how many people are stuck there because of ramps. Are we going to be responsible for providing the ramps for non-Medicaid so that they can transition? How far does this go? [Mary Beth Ribar] No. I mean, what the section Q is, is to, as we’ve been saying, is to ask the person if they want to talk to someone. Aging and disability resource center grants are to address all populations and people of all pay or sources. It’s an information source. That’s what we’re asking for. Give the person information. We’re not asking for them to provide ramps and these kind of things for people who aren’t on Medicaid. It’s information to that person on what’s available and what’s not available. That’s where our thought is right now. It’s not the actual provision of services for people who aren’t eligible. Just a little kind of a side, coming sometime this year is going to be this web presence portal for consumers to see what Medicaid services they’re eligible for, not what states offer in the way state plan services and all these things. It’s the whole administration and agencies push on transparency. And that will be the beginning of all consumers learning, “Okay, who is eligible for Medicaid or not? What can I get or not? What does my state offer or not? What are the caps or waivers or not?” And it will be a consumer — have a consumer interface to start to do that. And states will be putting — checking their information and keeping it current. So to answer your question, Ellen, no we don’t expect you to provide all this stuff to people who aren’t eligible for, all we’re asking is that someone come and talk to the person about what is possible in the community, depending on where they are. [Bob Mollica] Time for one more comment. Okay, David Letterman has his top 10. So I figured if I were David Letterman, I would have my ten highlights of what I’ve heard today, and my first one would be, take a breath. October 1 is the start date. It’s not the “Everything is up and running smoothly date.” The second point would be, you need time — it’s going to take time to define and implement the process, and including stakeholders that aren’t yet involved in it as soon as possible would be a valuable lesson that some of the other states have learned. Third point that I heard over and over again was that nursing homes should view you as a resource, and they should be — you should approach them and ask them to be part of the team. And while they might be concerned initially about the mortgage and their revenue flow, as Julia mentioned, other folks have had the experience that as the questions were resolved, and the experience was built that they learned that you are a valuable resource. The fourth is a point that I think Mark Gold made. Section Q is one tool, and it’s not the only way transition programs are going to identify people. It might be a way to identify people that don’t get into the system some other way, but it’s just one way. The fifth is that evidence based interventions were effective in showing that serving [spelled phonetically] private pay produced Medicaid savings. And in Minnesota they invested general revenue money to serve the private paid people that were in nursing homes and could transition with the expectation that they would, over time, delay access to waiver programs and admission to a nursing home and save the states money. And I would have loved to have been in that conversation where the program and policy staff used the evidence from an Indiana project and analyzed claims data to show that it would produce savings, because you know how skeptical budget planners are. Sixth, I think you really need to think about tracking what happens to people, not only people who transition to make sure that they’re receiving the support they need in the community, but also to identify the people who don’t transition to understand what the barriers are and to, over time, build capacity to address those barriers. Seventh, the point raised by Dawn Lambert [spelled] phonetically], she indicated that they were going to or considering designating a single entry point as the local community contact agency. And what does that — what impact does that have on other referral patterns? And maybe you could you think about protocols for determining when a typical referral pattern might be used and when a referral to the local contact agency might be the way to go. Next one is training is critical. Not only for — training transition coordinators about the process is as important as understanding what the resources are. As several folks have mentioned, nursing homes, social workers don’t always have the time to know what resources exist in the community, and especially if it takes time to dig them up or develop them, and transition coordinators as part of their jobs can do that. Case conferencing for complex cases seem like an interesting concept, sharing the experience of people with different parts of the state or — transition coordinators that sit right next to them. Just brainstorming can develop some options that might not otherwise have been apparent. And then I think that the last point is that we need an ongoing mechanism to learn from your experience over the next year or two or three. And whether that’s conference calls or meetings here to develop 3.01, I don’t know. But I think CMS is open. It’s clear that there are a number of issues that are going to be reexamined, and I assume the reason that Mary Beth asked you to send those to that website is that there are people involved in this process that need to hear beyond the people here at this table. So those are my top 10 takeaways, and I’ll turn it back to Mary Beth to do the final wrap up. [Mary Beth Ribar] Yeah, Melissa couldn’t come back this afternoon. There’s a lot going on at the office, as you can imagine. But first I wanted to thank everybody. First, everyone who participated in the conference, and especially Esellon [spelled phonetically] and Accoli [spelled phonetically] who did an exemplary job getting everything set up. [applause] Wonderful job. Thank you to everyone who helped present, all our states, everyone who helped with the panels, logistics, et cetera, and especially thanks to you guys. You are the ones who make this work. You’re the ones who are going to get this going. You’re the ones who know the real world. You’re the ones who are going to make the difference to each of those beneficiaries with access to information and choice and possible transition back. So thanks to you so much. Plan on participating in the May 12 teleconference, and we want to hear from you. Have a safe trip home. [applause] [end of transcript] CMS: MDS Module 3.0 Review 1 9/29/2010 Prepared by National Capitol Captioning 200 N. Glebe Rd. #710 (703) 243-9696 Arlington, VA 22203

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