protocol for fully functioning information & assistance - Western ...
protocol for fully functioning information & assistance - Western ...
protocol for fully functioning information & assistance - Western ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
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 />
15
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 />
16
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 />
17
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 />
18
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 />
19
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 />
20