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Aging and<br />

Disability<br />

Resource<br />

Network<br />

Protocol Series<br />

#3<br />

PROTOCOL FOR<br />

FULLY FUNCTIONING<br />

INFORMATION &<br />

ASSISTANCE<br />

VERSION 1<br />

May, 2012<br />

1


Table of Contents<br />

ADRN Protocol Series .................................................................................................................................... 3<br />

ADRN Partnership ......................................................................................................................................... 4<br />

Philosophy of the ADRN ................................................................................................................................ 4<br />

Service Operations ........................................................................................................................................ 4<br />

What is In<strong>for</strong>mation and Assistance? ........................................................................................................... 5<br />

Establishing Rapport ................................................................................................................................. 6<br />

Gathering In<strong>for</strong>mation (Discovery) ........................................................................................................... 6<br />

Selecting Providers .................................................................................................................................. 12<br />

Making Seamless Referrals ..................................................................................................................... 13<br />

Following-up ........................................................................................................................................... 14<br />

Advocacy and System Change ................................................................................................................ 16<br />

Qualities of the In<strong>for</strong>mation & Assistance Specialist .................................................................................. 17<br />

Capacity Building of In<strong>for</strong>mation & Assistance Specialists ......................................................................... 18<br />

Marketing, Outreach, and Public Education ............................................................................................... 20<br />

2


ADRN Protocol Series<br />

1. ADRN Interagency Network Data Sharing Agreement<br />

A. ADRN-MIS Standard Operating Protocol<br />

B. Protocol <strong>for</strong> Data Sharing within the Aging and Disability Resource Network<br />

[<strong>for</strong>thcoming]<br />

2. ADRN Operations Manual<br />

3. Protocol <strong>for</strong> Fully Functioning In<strong>for</strong>mation and Assistance<br />

4. Protocol <strong>for</strong> Fully Functioning Long Term Support Options Counseling<br />

A. Protocol <strong>for</strong> Seamless Access to HCBS Waivers<br />

5. Protocol <strong>for</strong> Fully Functioning Benefits Assistance<br />

A. Benefits Ladder<br />

B. Benefit Maps<br />

6. Protocol <strong>for</strong> Fully Functioning Family Caregiver Support Coordination [<strong>for</strong>thcoming]<br />

7. Protocol <strong>for</strong> Economic Casework and Service Coordination [<strong>for</strong>thcoming]<br />

8. Protocol <strong>for</strong> Handling Emergencies or Crises [<strong>for</strong>thcoming]<br />

9. Protocol <strong>for</strong> Disability Capable ADRN Services [<strong>for</strong>thcoming]<br />

10. Protocol <strong>for</strong> Aging Capable ADRN Services [<strong>for</strong>thcoming]<br />

11. Protocol <strong>for</strong> Dementia Capable ADRN Services [<strong>for</strong>thcoming]<br />

3


ADRN Partnership<br />

In<strong>for</strong>mation and Assistance is a core service of the Aging and Disability Resource Network<br />

(ADRN) provided by the Aging and Disability Resource Centers. Staff participate in collective<br />

program development, training and marketing as appropriate. A representative of each ADRC<br />

participates in regular meetings <strong>for</strong> coordination of ef<strong>for</strong>ts and ongoing program development<br />

and improvement.<br />

Philosophy of the ADRN<br />

There are several general principles followed by the ADRN staff:<br />

• Older persons and adults with disabilities are the focus of our services. Their needs, values<br />

and preferences are primary.<br />

• We strive to empower our consumers by balancing encouragement to use their own skills,<br />

abilities, and natural supports to manage <strong>for</strong>mal and in<strong>for</strong>mal resources effectively with<br />

helping them access long term services, supports, and public benefits.<br />

• We are an objective, reliable, and neutral source of in<strong>for</strong>mation on our five county region’s<br />

services and benefits <strong>for</strong> older adults and adults with disabilities.<br />

• We collect, house, and disseminate service in<strong>for</strong>mation according to our<br />

Inclusion/Exclusion and Conflict of Interest Policies.<br />

• We are non-sectarian and non-partisan in our approach.<br />

• We are sensitive to special populations and adults with disabilities. We make all ef<strong>for</strong>ts to<br />

use specialized services and/or assistive technology (e.g. TTY, Interpreters, etc.) <strong>for</strong> our<br />

consumers as appropriate.<br />

Service Operations<br />

The ADRCs while providing In<strong>for</strong>mation and Assistance (I&A):<br />

• Follow a similar call structure to ensure appropriate and consistent I&A service, typically:<br />

establishing rapport, gathering in<strong>for</strong>mation (discovery), exploring options (education and<br />

4


service identification), selecting providers, making seamless referrals, and following-up as<br />

needed.<br />

• Enable a caller to talk with a live person as much as possible.<br />

• Minimize the number of phone calls a person has to make to get to service providers by<br />

using facilitated referrals (make appointments <strong>for</strong> a consumer) or warm referrals (hold a 3-<br />

way phone call with the referent agency) as much as possible.<br />

• Encourage callers to use the least costly and least restrictive service(s).<br />

• Have telephone technology that includes a dedicated phone line and voicemail <strong>for</strong> the I&A<br />

Specialist, capacity to do warm referrals, etc.<br />

ADRN services are not structured as a crisis program. In crisis situations, staff will assess the<br />

urgency of the call and make appropriate referrals to providers who can handle crises. Individuals,<br />

who call outside of business hours and express they are in a personal crisis, will be instructed to<br />

call crisis hotlines as appropriate or 9-1-1 <strong>for</strong> an emergency. See ADRN “Protocol <strong>for</strong> Crisis<br />

Interventions.”<br />

What is In<strong>for</strong>mation and Assistance?<br />

Definition: In<strong>for</strong>mation and Assistance (I&A) is a service <strong>for</strong> adults with disabilities, older adults,<br />

their families/caregivers, and professionals that involves:<br />

• Identifying issues, strengths, and preferences to maintain independence; and<br />

• Opening doors and linking with the array of services that support community living,<br />

economic security, and health and wellness.<br />

The components of the I&A process are:<br />

• Establishing Rapport<br />

• Gathering In<strong>for</strong>mation (Discovery)<br />

• Exploring Options (Education and Service Identification)<br />

• Selecting Providers<br />

• Making Seamless Referrals<br />

• Following-up<br />

• Advocacy and System Development<br />

5


In<strong>for</strong>mation and Assistance is NOT:<br />

• Intake into an ADRC agency’s core services although I&A can lead to <strong>assistance</strong> with<br />

seamless access to the ADRC agency’s core services or to the services of external<br />

providers. Seamless intake involves determining eligibility, gathering documentation of<br />

eligibility when necessary, completing application and intake <strong>for</strong>ms, and arranging <strong>for</strong><br />

the start date of services.<br />

• Referrals made by non-ADRC staff (e.g. non-I&A Specialists such as Adult Protective<br />

Service Staff, Community Employment Specialists, etc.) in the normal course of business<br />

although they can make referrals to the ADRC I&A service or to external providers<br />

based on the expressed needs of a consumer.<br />

Refer to the AIRS Standards <strong>for</strong> Professional In<strong>for</strong>mation and Referral which are available at<br />

http://www.airs.org/.<br />

I&A involvement is generally expected to be short term, which is defined as 60 days or less,<br />

unless extenuating circumstances exist.<br />

The ADRC must have a system in place to ensure that people calling the ADRC speak directly to<br />

a live person during published service hours, as opposed to an answering machine, except<br />

during unusual circumstances.<br />

I&A Specialists will respond within 24 hours or within the next business day to new incoming<br />

calls. After the initial contact is made, I&A Specialists will send out written in<strong>for</strong>mation within 3<br />

business days and make appropriate referrals to outside agencies within 5 business days.<br />

Establishing Rapport<br />

The first job of the I&A Specialist is not to collect in<strong>for</strong>mation, but to establish rapport and let<br />

the caller tell his/her story.<br />

Gathering In<strong>for</strong>mation (Discovery)<br />

Initially the I&A Specialist must identify the intent of the caller, the intent of the consumer if<br />

different than the caller, needs/preferences, and the level of caregiver stress. To do this, s/he<br />

will follow the flow of the caller’s conversation and help him/her problem solve the issues,<br />

ideally without taking notes or typing. The in<strong>for</strong>mation collected is the foundation <strong>for</strong> the I&A<br />

Specialist’s work.<br />

In general, the I&A Specialist should ask open-ended questions such as “what type of <strong>assistance</strong><br />

are you looking <strong>for</strong>” or “describe a typical day,” or if the caregiver is the caller, “on a scale of 1-<br />

6


10, how would you rate your current stress level?” while listening <strong>for</strong> underlying problems or<br />

issues.<br />

Some questions that can guide the I&A Specialist through a comprehensive conversation<br />

related to the contact are as follows. The I&A Specialist will need to rearrange the order of the<br />

questions based on the openness of the caller and the initial in<strong>for</strong>mation s/he shares.<br />

Identity of Caller<br />

• Name, address, phone number<br />

• Relationship to older adult/person with a disability - family, friend, neighbor,<br />

professional<br />

• Contact by phone, walk in, letter, office appointment<br />

• How did they hear about the ADRC?<br />

Identity of Consumer:<br />

• Name, Address, Phone Number<br />

• Date of birth<br />

• Gender<br />

• Marital status<br />

• Ethnic background<br />

• Current living arrangement<br />

• Age group<br />

• Disability types: Can be more than one – and how they impact their lives.<br />

Intent of Caller:<br />

• Why are they calling today? What do they see the problem to be? What needs do they<br />

identify as primary?<br />

• What would the caller like to see happen as a result of their contact with the I& A unit<br />

today?<br />

Intent of Consumer:<br />

• Is the consumer the one calling?<br />

o If not, does s/he know that the call is being made today?<br />

• Is there anyone whom the consumer feels com<strong>for</strong>table asking <strong>for</strong> help?<br />

• Does the consumer feel threatened by other agency involvement?<br />

• Can the I&A Specialist call the consumer directly?<br />

• What are the consumer’s needs? preferences? values? short term and long term goals?<br />

7


Needs/Preferences/Values of Consumer and Caller<br />

It is often helpful to let the caller, if an older person/person with a disability, tell the I&A<br />

Specialist about a typical day. While the caller is talking, the I&A Specialist needs to listen <strong>for</strong><br />

the areas listed below and prompt them to talk about these areas as supportively as possible.<br />

What are the Consumer’s Primary Needs and Level of Support required?<br />

• Physical problems and strengths<br />

• Hospitalizations in the past 30 to 90 days<br />

• History of falls<br />

• Medications<br />

• Activities of daily living (ADL’s/IADL’s)-bathing, dressing, toileting, housekeeping, meal<br />

prep, lawn care, transportation<br />

• Cognitive status<br />

• Emotional Status- examples of depression or mental health concerns<br />

• Home environment-stairs, home conditions, adaptive aides in place or needs<br />

• Support network-family, friends, neighbors, church, existing agencies<br />

• Financial status-on benefit programs? Social Security, SSI, SSDI, Ability to meet basic<br />

needs with financial situation<br />

• Risk of institutionalization<br />

Are there indications of caregiver stress in the household and/or with caregivers who provide<br />

support?<br />

1. Rating of current stress level on a scale from 1-10 with 1 being no stress and 10 being<br />

extremely stressed?<br />

2. Experiencing an increase in illness? Cold, flu or intestinal problems?<br />

3. Receiving regular medical check- ups?<br />

4. Regularly spending time on activities s/he enjoys?<br />

5. Noticeable changes in sleeping habits since becoming a caregiver?<br />

6. Employment status?<br />

7. Feeling anxious or irritable more often?<br />

8. Having someone to talk to about his/her feelings?<br />

9. Having difficulty concentrating and making decisions?<br />

10. Satisfied with the amount of support from his/her family?<br />

11. Feeling others understand what s/he is going through?<br />

8


In<strong>for</strong>mation<br />

Assistance<br />

Contacts<br />

Anonymous Contact in ReferNET if:<br />

• No triggers suggesting that this person may need Benefits<br />

Assistance or Options Counseling<br />

• There is no need <strong>for</strong> an historic record on the person<br />

• Caller prefers to remain anonymous<br />

NO CLIENT RECORD CREATED IN REFERNET<br />

Create Client Record in ReferNET if:<br />

• Situation is urgent and/or requires need <strong>for</strong> an historic record<br />

• Possibility of multiple contacts<br />

• Triggers suggesting that this person may need Benefits<br />

Assistance or Options Counseling<br />

• The caller may need other services of the ADRC agency<br />

• Caller is willing to give his/her name and identifying<br />

in<strong>for</strong>mation<br />

CLIENT IS THE PERSON WHO NEEDS THE SERVICE<br />

Exploring Options (Education and Service Identification)<br />

The caller may need education about the services and the I&A Specialist must be<br />

knowledgeable about community resources, able to verbally explain the kinds of services<br />

available, and explore options.<br />

If during the initial communication between the I&A Specialist and the caller it becomes evident<br />

that the caller could benefit from one or several long term services and supports or other kinds<br />

of services, the I&A Specialist can directly ask the caller if s/he would like to consider enrolling<br />

in any of these services. Examples of long term services and supports are:<br />

• Adult Day Programs PH-1600.0500<br />

• Adult Residential Care Homes BH-8400.6000-040<br />

• Ambulance Services LD-1500.0600<br />

• Assisted Living Facilities BH-8400.6000-060<br />

• Assistive Technology Equipment (LH-0600 lower levels)<br />

• Home Barrier Evaluation/Removal BH-3000.3500<br />

• Home Delivered Meals BD-5000.3500<br />

9


• Home Health Aide Services - LT-2800.3000<br />

• Home Nursing - LT-2800.3100<br />

• Homemaker PH-3300.3000<br />

• In Home Assistance (PH-3300 – lower levels)<br />

• Independent Living Skills Instruction LR-3200<br />

• Medical Equipment/Supplies (LH-5000 lower levels)<br />

• Medical Transportation BT-4500.6500-500<br />

• Nutrition Assessment Services LF-4900.6200<br />

• Paratransit (BT-450.650)<br />

• Personal Care PH-3300.6500<br />

• Personal Emergency Response Systems PH-1800.6260<br />

• Pest Control Services JP-6500.6500<br />

• Senior Ride Programs BT-4500.6500-800<br />

Examples of other services:<br />

• Food pantries<br />

• Mental health services<br />

• Socialization services<br />

• Health services<br />

These guidelines can help when helping a caller determine the best service or package of<br />

services:<br />

• Begin with the least restrictive and least costly types of services i.e., home delivered<br />

meals, lifeline, friendly visitor on the service continuum.<br />

• Describe services in the <strong>for</strong>m of an action plan - <strong>for</strong> example, “first, you may want to try<br />

this service as it is simple to set up and inexpensive; next, you will want to call<br />

PASSPORT <strong>for</strong> a full assessment etc. and explain what they might expect as they contact<br />

agencies or apply <strong>for</strong> benefits.<br />

• Group services by options along the continuum of care i.e., services that are provided in<br />

the home, intermediate level of care in assisted living or apartment living, skilled level<br />

of care services-nursing homes, etc.<br />

• Refrain from overwhelming the caller with too many choices as the I&A Specialist can<br />

always call them back.<br />

• Engage in initial <strong>assistance</strong> with decision support, i.e., helping the caller weigh the pros<br />

and cons of choosing certain services, their cost, and location. For example, choosing<br />

assisted living at a certain cost is much more expensive than bringing in meals and a<br />

10


housekeeper. When more complex decision support is needed, a referral should be<br />

made <strong>for</strong> Long Term Care Options Counseling.<br />

The I&A Specialist should listen <strong>for</strong> cues that signal the person is at the point of decision-making<br />

such as maybe I… I don’t know… Someone told me I need… or I can’t… and ask him/her directly<br />

if s/he would like additional support thinking through options and making choices. In addition,<br />

if the I&A Specialist thinks the consumer could use public benefits, s/he can directly ask the<br />

caller if s/he would like <strong>assistance</strong> applying <strong>for</strong> public benefits<br />

The more knowledge of the range of long term services and supports that the I&A Specialist<br />

has, the more effective s/he will be in identifying services that match the caller’s needs.<br />

The In<strong>for</strong>mation Assistance and Options Counseling Committee will review and approve existing<br />

resource materials to be disseminated by the ADRCs as well as resources to be included on the<br />

ADRC section of each partner’s website. The Committee will also create in<strong>for</strong>mational<br />

materials that currently do not exist or that exist, but need to be customized. Each ADRC should<br />

keep a supply of resource materials at their center <strong>for</strong> dissemination to their consumers.<br />

Based on the needs of the consumer, the I&A Specialist can mail a customized packet of<br />

in<strong>for</strong>mational flyers to a caller within 3 working days of the call with a note that identifies the<br />

ADRC, personalized as appropriate.<br />

11


Selecting Providers<br />

Once the I&A Specialist has discussed options <strong>for</strong> services, s/he can use the resource database<br />

in ReferNET and other resource sources, including www.Medicare.gov to help the caller select<br />

providers. It is essential that the ADRC remain and be perceived as an objective, reliable, and<br />

neutral source of in<strong>for</strong>mation on services <strong>for</strong> adults with disabilities and older adults in the<br />

region. The I&A Specialist can explain to the caller that providers are included in the ReferNET<br />

database based on the Inclusion/Exclusion Policy and the Conflict of Interest Policy and that it is<br />

imperative that the caller evaluate each provider and make the final selection. S/he may also<br />

go to (or refer a caller to) www.Medicare.gov <strong>for</strong> quality indicators on hospitals, nursing<br />

facilities, and home health agencies and provide that in<strong>for</strong>mation to the caller. In addition, a<br />

referral can be made to the Long Term Care Ombudsman (LTCO) program so the caller can<br />

obtain complaint in<strong>for</strong>mation as they make their provider selection.<br />

It should be noted that not all individuals needing <strong>assistance</strong> in locating hands-on or chore<br />

service providers want or need to work with a home health agency or other <strong>for</strong>mal caregiving<br />

providers. Some Ohio Medicaid Waivers have provisions whereby individuals can hire and<br />

manage their own providers. Others are not Medicaid eligible or are able to pay privately <strong>for</strong><br />

these services. There is not one central repository <strong>for</strong> lists of independent providers although<br />

the Ohio Department of Job and Family Services (ODJFS) does maintain a state-wide provider<br />

list of non-agency independent contractors on its website:<br />

https://portal.ohmits.com/Public/Public%20In<strong>for</strong>mation/Search%20Provider%20Directory/tabId/61/Defau<br />

lt.aspx ADRC staff may call LEAP at this point <strong>for</strong> <strong>assistance</strong> in identifying independent providers<br />

and other supports to meet the individual’s needs.<br />

Selection of providers should be based on the in<strong>for</strong>mation gathered during Discovery and the<br />

Service Education/Identification processes. Selection criteria can include: location near<br />

consumer or caregiver’s home; near caregiver’s place of employment; cost; amenities; religious<br />

or cultural background; whether there is a provider waiting list; scope of available services; etc.<br />

The I&A Specialist should reassure the caller that s/he can mail written in<strong>for</strong>mation to support<br />

the discussion. S/he should also assess the capacity of the caller to handle referrals <strong>for</strong> multiple<br />

services/providers and prioritize needs. The process can be sequenced over several steps to<br />

ensure the caller is linked to the most essential service(s) first.<br />

ReferNET should be used to track referrals and feedback on experience of the caller that can be<br />

gained in follow-up contacts.<br />

12


The In<strong>for</strong>mation Assistance and Option Counseling Committee will work with the 2-1-1s on the<br />

Inclusion/Exclusion Policy that includes providers in ReferNET and other providers not in<br />

ReferNET. The Committee will also develop a Conflict of Interest Policy.<br />

All resources in ReferNET must be given to callers. I&A Specialists must not make qualitative<br />

judgments about a provider without some quantitative or objective in<strong>for</strong>mation to back that<br />

up. Through a systematic process in collaboration with the 2-1-1s and based on the<br />

Inclusion/Exclusion policy, some providers may be removed from the database. Referrals to<br />

other providers that are not in the ReferNET database need to be vetted through a systematic<br />

process.<br />

Making Seamless Referrals<br />

The following types of referrals can be made to expedite a seamless referral to a provider.<br />

Type Characteristics Possible Advantages and<br />

Disadvantages<br />

Passive<br />

referral<br />

The caller is given contact<br />

in<strong>for</strong>mation <strong>for</strong> appropriate<br />

service(s) and is left to make<br />

her/his own contact at a time<br />

that best suits the<br />

caller/consumer.<br />

This process gives responsibility<br />

to the caller to take action on<br />

his/her own behalf. However,<br />

there is a greater likelihood that<br />

the referral will not be taken up.<br />

Consumer In<strong>for</strong>mation<br />

Provided<br />

None; the consumer<br />

tells his/her story to<br />

the referent<br />

provider(s).<br />

Facilitated<br />

referral<br />

The caller is helped to access The other service is made aware<br />

the other service, <strong>for</strong> example, of the caller, and the caller is<br />

the referring organization makes helped to access that other<br />

an appointment with the other service. The caller may need to<br />

service on the caller’s behalf, asks wait <strong>for</strong> a response to the other<br />

the other service to make contact service.<br />

with the caller or a caller is<br />

transferred to the other service.<br />

With verbal permission of<br />

the consumer, the I&A<br />

Specialist can provide the<br />

referent agency with the<br />

Basic Consumer Sketch<br />

data in ReferNET and<br />

other data as<br />

appropriate, including the<br />

purpose of the referral.<br />

The consumer does not<br />

need to repeat all of<br />

their story to the agency<br />

to which the caller is<br />

referred and has relevant<br />

in<strong>for</strong>mation about<br />

the consumer.<br />

13


Type Characteristics Possible Advantages and<br />

Disadvantages<br />

Consumer In<strong>for</strong>mation<br />

Provided<br />

Warm<br />

referral<br />

A ‘live’ three way conversation<br />

in the presence of the caller<br />

(whether face to face or by<br />

telephone) in which the ADRC<br />

introduces the caller, explains<br />

what has already been done to<br />

This provides an open and<br />

transparent process in which<br />

in<strong>for</strong>mation can be<br />

exchanged between the ADRC,<br />

the caller and the other service<br />

provider. Issues can be clarified<br />

assist him/her and the purpose of immediately. The caller does<br />

the referral.<br />

not need to repeat all of his/her<br />

story. The process relies on<br />

someone being available at the<br />

other service at the time the<br />

caller is to be referred.<br />

Same as above; but with<br />

greater opportunity to<br />

explain in<strong>for</strong>mation<br />

exchanged.<br />

A cold referral to a provider should never be made. This is when the caller is transferred to<br />

another service, without any immediate communication between the ADRC and the other<br />

services, <strong>for</strong> example, by putting the caller into a call answering service. The other service may<br />

be unaware of the nature of the call or of any in<strong>for</strong>mation or services that have already been<br />

provided. The caller may be frustrated that they have to re-tell their story or may not<br />

communicate their needs in a way that allows the other service to see why the caller has<br />

been referred.<br />

The In<strong>for</strong>mation and Assistance Specialist can also make a referral to the Options Counselor to<br />

assist the consumer with initiating the application process <strong>for</strong> specific services with providers<br />

with whom special <strong>protocol</strong>s have been agreed to.<br />

Following-up<br />

Definition: Follow-up is contact [typically, but not always by telephone] with a consumer following one<br />

or several referrals to provider agencies. It can have multiple purposes:<br />

• Finding out whether the consumer received the in<strong>for</strong>mation that was sent, understands<br />

the in<strong>for</strong>mation, and has follow-up questions;<br />

• Finding out if the caller needs <strong>assistance</strong> getting connected with service in<strong>for</strong>mation<br />

provided;<br />

• Finding out what the caller’s experience has been with the referrals given;<br />

• Finding out if the caller needs advocacy or <strong>assistance</strong> with an appeals; and<br />

14


• Checking on the caller’s safety if risk issues were identified.<br />

Follow-up occurs after one or several referrals have been made. The I&A Specialist should<br />

in<strong>for</strong>m callers that they can call back with more questions at any time.<br />

If a caller agrees or wishes to have a follow-up call, s/he will need to leave their name and<br />

number. The I&A Specialist will ask permission to make a follow-up call and whether s/he is<br />

able to leave a message when s/he tries to call. At a minimum, completed follow-ups will occur<br />

with 30% of contacts.<br />

It is necessary to follow-up when:<br />

• There is a situation involving crisis, emergency or endangerment (There is a separate<br />

<strong>protocol</strong> <strong>for</strong> this.);<br />

• Basic needs of food, clothing and shelter were identified as primary issues and the caller<br />

does not appear to have the necessary capacity to follow through and resolve their<br />

problems;<br />

• There are complex problems and multiple referrals;<br />

• The amount of in<strong>for</strong>mation may overload the consumer and it does not appear that the<br />

caller will be able to proceed with the in<strong>for</strong>mation independently (e.g. an individual who<br />

has a hard time writing down the phone number of the referent agency);<br />

• There is a caller who is very frail and has issues beyond the initial reason <strong>for</strong> the call (e.g. slow<br />

learning; extreme situation at home; language barrier, etc.);<br />

• The person is unsure, upset or disappointed;<br />

• An application needs to be submitted by or on behalf of the consumer;<br />

• In<strong>for</strong>mation has been sent to the person;<br />

• There has been a history of problems with the organization to which a referral is made;<br />

• The I&A Specialist is dealing with new or unfamiliar services or providers; or<br />

• There is a complaint.<br />

It is not necessary to follow-up when:<br />

• The conversation is brief and specific, as in a request <strong>for</strong> a phone number or a simple<br />

referral.<br />

• The consumer has indicated that he or she does not wish to have a follow up contact.<br />

Follow-up <strong>for</strong> initial contacts will be completed within 30 days of the original call or within 2<br />

business days in an urgent situation.<br />

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In general, the I&A Specialist will:<br />

• Use professional judgment regarding when to follow up. Follow up does not do any<br />

harm, so it is better to err on the side of overdoing it.<br />

• Ask permission to follow-up.<br />

• Make sure s/he is talking to the right person during the follow-up call.<br />

• Avoid disclosing sensitive in<strong>for</strong>mation or violating confidentiality.<br />

• Keep records of follow-up activity in ReferNET.<br />

• Refer to an Options Counselor or another staff person <strong>for</strong> a face-to-face or home visit when a<br />

person does not appear to be able to follow through on referrals without <strong>assistance</strong> when the<br />

I&A Specialist calls back, when <strong>assistance</strong> is needed, and <strong>for</strong> seamless access to publicly funded<br />

services.<br />

If, during the initial communication between the I&A Specialist and the caller (or with any<br />

other ADRC agency staff), it becomes evident that the caller is in crisis, the I&A Specialist will<br />

follow the companion ADRN Crisis Intervention Protocol.<br />

Following-up<br />

Intent:<br />

• To help the<br />

caller link to<br />

needed services<br />

Follow-up:<br />

The process of contacting callers to determine whether their<br />

needs have been met as a result of the referrals provided and if<br />

not, why not. Possible outcomes:<br />

• Caller follow up on referral and need was met<br />

• Caller did not follow-up on the referral. Depending on the<br />

time between the referral and the follow-up, it is possible<br />

that the caller is still thinking about the next steps, discussing<br />

it with family members or has been busy with other issues.<br />

• Caller followed up on referral, but the need was not met<br />

either because the caller received inaccurate in<strong>for</strong>mation,<br />

denial of service following assessment, waiting lists,<br />

af<strong>for</strong>dability<br />

• Additional in<strong>for</strong>mation or <strong>assistance</strong> is needed<br />

Advocacy and System Change<br />

When an I&A Specialist is assisting a consumer of publicly funded services with seamless access,<br />

s/he may discover systemic barriers to a consumer accessing the service. Again each ADRC can<br />

respond individually to this in<strong>for</strong>mation by working with the administering body of the service<br />

or with public elected officials to correct the problem or the ADRN can look at this collectively<br />

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when the pattern exists across multiple ADRCs. Encouraging consumers to file complaints with<br />

the Long Term Care Ombudsman program <strong>for</strong> specific long term services and supports may also<br />

lead to system change.<br />

Qualities of the<br />

In<strong>for</strong>mation & Assistance Specialist<br />

The In<strong>for</strong>mation & Assistance Specialist must be:<br />

• Knowledgeable about the range of long terms services and supports and able to educate<br />

callers about the services<br />

• Skillful in using the ReferNET software and the ADRN enhanced resource database while<br />

on the phone with the caller<br />

• Professionally perceptive about helping the caller obtain in<strong>for</strong>mation about services<br />

appropriate <strong>for</strong> them and providers that reflect their needs, values, preferences<br />

• Able to communicate complex in<strong>for</strong>mation in a manner in which the consumer can<br />

understand<br />

• Sensitive to the needs of a caller who could benefit as a consumer of other more intense<br />

ADRC services (Options Counseling, Benefits Assistance, Short Term Care Coordination)<br />

• Skillful in assisting the caller with seamless transitions to other ADRC services, other<br />

ADRC Agency Core Services, and other publicly funded services<br />

• Skillful in seamlessly referring the caller to Adult Protective Services and LTCO<br />

• Able to make referrals to external service providers<br />

• Efficient and effective following up with the caller/consumer<br />

• Skillful in completing necessary electronic reports<br />

• Aware of other ADRN partner agency specialties<br />

Understand the nature of the call<br />

Intent of Caller:<br />

In<strong>for</strong>mation Assistance<br />

• What does the caller view as the reason <strong>for</strong> the call?<br />

• What does the caller identify?<br />

• Is there a reason to think the caller has greater needs than are apparent from the request?<br />

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Capacity Building of In<strong>for</strong>mation &<br />

Assistance Specialists<br />

In<strong>for</strong>mation and Assistance Specialists are required to become CRS-A certified within 12 months<br />

of being hired or in accordance with AIRS policy:<br />

• At least one year of employment in In<strong>for</strong>mation and Referral (I&R) <strong>for</strong> applicants with a<br />

Bachelors or higher degree<br />

• Two years of employment in I&R <strong>for</strong> applicants with Associates/Community College<br />

degree<br />

• Three years of employment in I&R <strong>for</strong> applicants with a high school diploma or GED<br />

• Five years of I&R employment with no educational qualifications.<br />

New hires will have intense opportunities <strong>for</strong> shadowing others in their own agency or in<br />

another ADRN Partner Agency and will have 2 calls per week monitored by his/her supervisor.<br />

Ongoing staff will have 2 calls per month monitored. If a supervisor is monitoring a call, there<br />

should be a message to the caller: “Your call may be monitored <strong>for</strong> quality assurance purposes.”<br />

Secret shopper callings is another method of monitoring quality. Opportunities are available to<br />

all I&A Specialists to brainstorm challenging consumer cases.<br />

Agent:<br />

Date/Time/<br />

Record #:<br />

Supervisor:<br />

Topic/Client Need or<br />

Situation:<br />

CALL MONITORING FEEDBACK FORM<br />

Note: A rating of Not Acceptable is given when the outcome is detrimental to the consumer<br />

(consumer would have a negative experience) or to the ADRN Partner Agency. Requires<br />

immediate correction.<br />

Score<br />

1. OPENING/CLOSING:<br />

Friendly, welcoming tone of voice, uses appropriate greeting (identifies agency and self),<br />

uses appropriate closing (encourages further contact), call flagged <strong>for</strong> follow-up upon<br />

closing when necessary.<br />

0=not acceptable; 3=correction/coaching needed 5=meets expectations<br />

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2. ASSESSMENT:<br />

Assesses needs accurately by asking the right questions and listening, uses tactful<br />

probing, clarifies caller’s need when necessary.<br />

0=not acceptable; 5=correction/coaching needed 10=meets expectations<br />

3. INFORMATION:<br />

Provides appropriate resources from the database, gives accurate in<strong>for</strong>mation, gives<br />

alternatives when needed, provides enough in<strong>for</strong>mation/detail <strong>for</strong> the caller to follow<br />

through, avoids giving advice.<br />

0=not acceptable; 30=correction/coaching needed 40=meets expectations<br />

4. COMMUNICATION SKILLS:<br />

Uses appropriate tone of voice, volume, inflection and pitch. Responds in a nonjudgmental<br />

and culturally appropriate way. Paces call properly, does not rush caller,<br />

interrupt caller, or engage the caller in overly lengthy conversation. Avoids counseling.<br />

0=not acceptable; 20=correction/coaching needed 30=meets expectations<br />

5. PROCEDURAL:<br />

Uses hold, transfer and conference appropriately, does not disconnect caller, records<br />

demographics and call appropriately, follows ADRN policies and procedures.<br />

0=not acceptable; 10=correction/coaching needed 15=meets expectations<br />

Total<br />

This call was handled very well. Excellent job!<br />

Comments:<br />

I & A Specialist:______________________________________<br />

Date:___________________________________________<br />

Supervisor:______________________________________<br />

Caller:__________________________________________<br />

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Marketing, Outreach, and Public<br />

Education<br />

Marketing and outreach activities of the ADRC are critical so people know about the programs<br />

and services the ADRC offers. Older adults, adults with disabilities and their caregivers benefit<br />

most from the ADRC if they are aware of the services offered at the earliest stages of need. The<br />

ADRC responds regularly to requests <strong>for</strong> presentations <strong>for</strong> community groups, professional<br />

associations, academic institutions and community boards. Consistent with the ADRN<br />

marketing plan, the ADRC participates in community vendor fairs, local church requests <strong>for</strong><br />

booths and local workshop events where a booth space is offered. The ADRC tracks the<br />

attendance, effectiveness, and response to these events in order to improve our ability to<br />

target the potential audience and make our presence at presentation and booths as valuable as<br />

possible. Each ADRC establishes a minimum monthly goal of number of presentations/booths<br />

or outreach activities.<br />

The ADRC Agency website is a valuable component of reaching long distance caregivers and<br />

assisting professionals in the community who serve the ADRC target populations.<br />

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