Transitions and Long-Term Care: The Minimum Data Set 3.0 Section ...

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20Challenges• Ongoing outreach and education to nursing homes(NH)• NH making effective referrals, knowing who to contact• NH and LCA making connections to work together forresident in person-centered approach• Implementation of an effective referral and transitionplanningprocess at local level, i.e., LCA, Area Agencieson Aging (AAA), Aging and Disability Resource Centers(ADRC), MFP, and other stakeholders
21New Opportunities• AoA, CMS, and Veterans Affairs (VA) workingtogether to provide information and resourcesfor each Agency and their Stakeholders• State VA programs and funding streams vary• Goal is to work for Veterans in a person-centeredapproach for appropriate referrals and to meettransition planning needs• Veterans in NHs and State Veterans Homesdepending on length of service and level of VAbenefits can be eligible for wrap-aroundMedicaid and other services
Page 5 and 6: 5Minimum Data Set (MDS) 3.0• Nurs
Page 7 and 8: 7Results of the Dialogue• Many pr
Page 9 and 10: 9Intent of Changes• Adopt a more
Page 11 and 12: 11Current VersionChanges to Section
Page 13 and 14: 13Changes to Section Q (continued)Q
Page 19: 19Expected Impacts (continued)• B
Page 23 and 24: Money Follows the PersonRebalancing
Page 25 and 26: 25Current CMS RebalancingOptions•
Page 27 and 28: MFP States27
Page 29 and 30: 29MFP Quality ManagementSystem• I
Page 31 and 32: 31MFP Transitions by PopulationDist
Page 33 and 34: MDS 3.0 Section Q, MFP and theAging
Page 35 and 36: 35The Aging Network• Established
Page 37 and 38: 37Providing Information about Homea
Page 39 and 40: 39Role of ADRCs (cont’d)• CMS a
Page 41 and 42: 41State and Local Level PolicyDevel
Page 43 and 44: 43Ombudsman Resident Advocacy(conti
Page 45 and 46: 45Integrating Functions Across Core
Page 47 and 48: 47Section Q Successes• Residents
Page 49 and 50: NC’s “No Frills” Presentation
Page 51 and 52: 51Brief Overview of ADRC Set-Up inN
Page 53 and 54: 53LCA Current Structure• DMA/MFP
Page 55 and 56: 55Lessons Learned:What Works• Wha
Page 57 and 58: 57Emerging Opportunities• Partner
Page 59 and 60: 59Resources: MDS 3.0 Section Q• h
Page 61 and 62: 61Resources: Affordable Care Act•
Page 63: 63Questions/Comments/Stories/Sugges

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