NILP, and The ESMV are pleased to present:

The Long Term Care Options Counseling Program (LTCOC)

The The Elder Services of the Merrimack Valley, Inc. (ESMV) and Northeast Independent Living Program (NILP) developed the first Aging and Disability Resource Consortium (ADRC) in Massachusetts in 2003. We found then that we had very similar missions which is to provide the people in need of long term care support the choices they need to live a life of dignity and independence. This meant that we believed in promoting the full integration of long term care information and referral services, benefits and options counseling on all available options, and assuring access to publicly funded and privately funded services to benefit those in need of long term supports. We employ a "No Wrong Door" approach in our ADRC and have a wide circle of partners that include; The Department of Mental Health (DMH), Department of Mental Retardation (DMR), Massachusetts Rehab Commission (MRC), The Statewide Head Injury Program (SHIP) and The Massachusetts Commission for the Blind (MCB) and the Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH) as well as numerous other health and social service program providers.

Since July 2005, all the partners of the ADRC have been collaborating through monthly and/or quarterly meetings in a team called the Community Transition Team (CTT). The CTT consists of nurses and case managers of each of the named agencies. The Community Transition Teams purpose is the following:

• Monthly meetings to sit down and work together on shared clients who are looking to transition out of a nursing facility into the community. These are brainstorming meetings where we not only find solutions for the situation at hand but learn about the array of services each partner brings to the table.
• Cross trainings among each other to learn more about each other’s programs and services. We developed a consultation committee contact sheet for other staff members to have a contact person and number at each agency.
• Consumer empowerment, choice and the right to fail. This is a culture and belief so strongly embedded in the ILC movement has been fully embraced by ESMV. It is one that has caused us to examine all our efforts from I&R to providing care for very vulnerable and high risk clients. We have all benefited from the many discussions on this topic and we believe it has made our whole network of providers stronger.
• Joint trainings. The ADRC has sponsored many trainings. Recently a paradigm shift was evident when all the members of our ADRC volunteered to present at a network meeting held at ESMV in June 2006. The guests were the nursing facility social workers and discharge planners and the topic was “Consumer-directed care and the ADRC.”

As the lead partners, ESMV and NILP provide invaluable, and unique set of services that are tailored to meet the particular needs of individuals who are working to get themselves out on nursing homes and institutions:

1. Access to services in a timely and appropriate manner based on their situation and/or disability. Together we identify consumers needing LTC-OC by first utilizing our current direct service staff who are trained to identify consumers needing LTC-OC. Those who work as Elder Care Advisors, Information and Referral Specialists, Liaisons, Peer Counselors, Advocates, Skills Specialists and those RN’s and CM's on the CSSM team have all attended the trainings from EOEA. LTC-OC includes an "assessment" of the consumer's financial status, functional status, their formal and informal support system, their values and preferences pertaining to long term care options. We provide, wherever possible, LTC-OC to the consumer before they have a nursing facility admission. If a person is identified as needing services, a referral is made to the appropriate agency.
2. Individuals receive comprehensive and unbiased information. Staff of the ADRC are in a unique position because we have already established good working relationships with each other, understand each others services and have the benefit of 5 years of working with each other. We do excellent coordination with other ADRC's, ASAP's or ILC's for consumers who want live in our area but are hospitalized in another area who lives elsewhere. We have developed an Aging and Disability Resource Guide which is called The Green Book. A consumer receiving LTC-OC will receive this as well as a packet of information on services and options. This packet could be further customized based on what the needs are that are presented. Please contact us if you would like to have one.
3. Personal goals, values and preferences are fully honored. The ADRC of the Merrimack Valley puts a consumer's values and preferences as a high priority. This is consistently addressed in the first interview with the consumer utilizing a Value and Preference Assessment from the National LTC Resource Center from the University of Minnesota. In addition, we ask the consumer along the way to assure that the consumer feels their personal goals, preferences and values have been honored.
4. Individuals receive the support needed to make decisions about LTC options. The LTC-OC Team assists the individual in getting the support they need. This may include one on one discussion about their decisions, facilitating family meetings, or participating in discharge planning meetings. Additional supportive counseling such as working with the caregiver program and caregivers and/or any written material is provided to the consumer clarifying the pros and cons of their options. When a consumer, caregiver or family needs further counseling and case management a transition to the appropriate department or agency is made seamlessly.
5. Persons providing LTC-OC have the skills and knowledge to carry out these activities. Our LTC-OC staff are team based. Staff from both ESMV and NILP sit and work together in one location. We believe the team model reinforces the very culture of empowerment we hope to provide to our consumers. The team will be cross functionally trained in order for the consumer, respective hospitals, nursing and rehab facilities will view our presence as one coordinated service delivery plan. Our staff includes: professional licensure in social work, Registered Nurses, Master's level Counseling and Education and Training and Certified Skills Specialists. Professional Development and training are central to the cross functional model. Cultural Competency and Disability Culture Competency are required for all staff involved in the program.
6. The provision of LTC-OC shall not impact the time sensitive requirements of discharge planning or admission processes at hospitals and nursing facilities. Our goal is to develop strong relationships with social work and discharge planners so that we are in a good position to assist them in any way necessary. We are available to follow up on any patient of the hospitals we identify and collaborate on the discharge planning process. We are established at key Rehabilitation Facilities and all skilled Nursing Facilities in the area because we believe many referral to nursing homes occur from these facilities and should benefit from the counseling necessary to make informed decisions. We work together to assure the consumer has the information they need to make the best decision for themselves. LTC-OC gives us the opportunity to be pro-active at all levels of the continuum of care.
7. LTC-OC services meet the consumer/recipient expectations established in this Program Instruction. Throughout the assessment process staff will be asking the consumer "how can we best help you" and "does this meet your needs?" We developed a consumer survey to assure we are meeting their expectations with a high degree of satisfaction. The LTC-OC team follows up and contacts consumers to assure their needs were met.

Our model initially targeted the Greater Haverhill area of the Merrimack Valley. Two hospitals Merrimack Valley Hospital in Haverhill and Anna Jacques Hospital in Newburyport and the rehabilitation hospitals predominantly serving consumers in this area: Whittier Rehabilitation Facility in Bradford and Northeast Rehabilitation in Salem NH. Since we do not know what the volume of work will be in the 11 communities and the 4 facilities we have targeted just in this area of our region. Our strategy will be to expand if time and resources allow. We also would like to have a presence in The Spaulding Rehabilitation in Boston as many of our consumers seek this facility for their rehabilitation needs. Since it is outside of our immediate area we intend to reach out on a periodic basis, provide education about Long Term Options and work on building good relationships with their discharge planners. In the future, we would like to expand into the other hospitals in our area. The next would likely be the Lawrence General Hospital in Lawrence and Holy Family Hospital in Methuen and finally the 2 hospitals in the Greater Lowell area both Saints Memorial and Lowell General Hospital which are likely to have a very high volume of consumers.

We believe that person centered, consumer driven counseling should be innate in all of our staff. For this reason we have identified two staff development managers for the EOEA sponsored "train the trainer" training in Consumer directed care and will incorporate this training in all our homecare staff and ADRC partners. We also feel that the basic intent of the LTC-OC initiative can and should occur as early on in the process of care as possible and reach the consumers and caregivers well before the decision of long term care is upon them. Due to the fact that pre-admission planning cannot happen in the same place for all consumers and families, it is important to have good working relationships with all long term care providers. These could include the Assisted Livings, rest homes and group homes in our area.

For more information, we welcome you to contact:

Jenny Pickett
LTCOC Coordinator
Northeast Independent Living Program, Inc.
20 Ballard Road, Lawrence, MA 01843
Tel: (978) 687-4288 v/tty
Fax: (978) 689-4488