Virtual Site Visit: New Hampshire

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1 Virtual Site Visit: New Hampshire 1 Moderators: Carrie Blakeway, The Lewin Group Christina Neill, The Lewin Group Panelists: Mary Maggioncalda, Administrator, NH Bureau of Elderly & Adult Services (BEAS) Wendi Aultman,ADRC Program Manager, BEAS Lisa Morris, Center Manager, ServiceLink Resource Center (SLRC) of Belknap County Nancy Bacon, Long Term Support Counselor, SLRC of Belknap County Ellie Donnelly, Information & Referral Specialist, SLRC of Belknap County Jan Fiske, Family Services Specialist, NH Division of Family Assistance Carol McCall, RN, Long Term Care Nurse, NH BEAS Virtual Site Visit: New Hampshire You will learn about: 2 How the model started The roles of BEAS ServiceLink Resource Center goals and services Establishing the model in the community The roles of all Resource Center staff Applying the model to your community Lessons learned 1

2 NH ServiceLink Resource Centers Berlin Littleton 4 Belknap County Merrimack County Laconia Concord Carroll County Monadnock Region Tamworth Keene Coos County Rockingham County Berlin Portsmouth Grafton County Salem Lebanon Strafford County Littleton Rochester Hillsborough County Sullivan County Manchester Claremont Nashua Lebanon Claremont Keene Nashua Tamworth Laconia Rochester Concord Portsmouth Manchester Salem 2

3 The ServiceLink Resource Center Vision The ServiceLink Resource Center envisions communities that empower and support citizens to make the personal decisions, plans and social connections that allow them to live as independently and fully as possible. 5 The ServiceLink Model Historical Development 1998 NH State Legislature Senate Bill 409 Reform system of long term care Establishment of network of community-based sites to provide I&R/A for elders and people living with chronic illness/disabilities; 13 non-profit agencies entered into contracts with BEAS (Bureau of Elderly & Adult Services) to provide these services statewide. 6 3

4 The Role of BEAS Leadership Funding Training Technical Assistance Statewide Education 7 The ADRC Grant 2003 ADRC grantee ADRC model built upon existing ServiceLink model Piloted 2 counties in December 2004 Piloted additional 3 counties in January 2006 Statewide implementation by January

5 The ADRC Grant 9 The ADRC grant awarded in 2003 enabled the ServiceLink model to: Develop Family Caregiver education curriculum/program. Manage the evaluation of the program through contract with New Hampshire Survey Center. Support Statewide Advisory Board. Lease a centralized information and referral system, resource database, public accessible website. Contract with a technical assistance consultant to refine the NH ADRC model. What is the NH ServiceLink Resource Center Network? A state-wide public/private partnership between the NH Bureau of Elderly & Adult Services and a network of locally administered non-profit agencies. This network consists of thirteen ServiceLink Resource Centers (SLRC) and 40 satellite offices located throughout NH. 10 The ServiceLink program is administered at the community level by staff who know the community first hand. 5

6 Who are ServiceLink Resource Centers Designed to Assist? The Resource Centers Assist: Adults age 60 or older; Adults age 18 and above living with a disability or chronic illness; Caregivers; and Anyone interested in long-term support information and services. 11 Information & Assistance is provided regardless of income or resources. ServiceLink Resource Center Goals To be the single entry point on a full range of long term support options and services. To be accessible and visible in the community. To be a trusted source of unbiased information for public & private pay individuals. 12 6

7 ServiceLink Resource Centers Provide A single point of entry to public programs including NH funded Medicaid nursing facility care and the community based long term care waiver program for the elderly & chronically ill (HCBC-ECI). One-on-one assessment of needs in the office and home settings. Assistance in accessing services and help in taking the next steps. Counseling to help people plan ahead for their long term care needs. 13 Centralized resource management, data collection, and evaluation. ServiceLink Resource Center Team 14 Belknap County 780 N. Main St. Laconia, NH Lisa Morris, CIRS-A Center Manager Nancy Bacon, CIRS-A Long Term Support Counselor Ellie Donnelly, CIRS-A Information & Referral Specialist Carol McCall, RN LTS Nurse, BEAS Jan Fisk, Family Services Specialist, DFA Bureau of Elderly Adult Services 129 Pleasant St. Concord, NH Mary Maggioncalda Administrator, Program Planning Wendi Aultman, MS, CIRS-A, ServiceLink Program Manager Jennifer Hosue, CIRS-A ServiceLink Network Coordinator

8 The ADRC Model in the Community 15 Establishing the Resource Center Model in the Community Public/Private Partnerships Establishing relationships with providers, community leaders, and citizens is vital to being viewed as a collaborator, expert, and resource: Bureau of Elderly & Adult Services Steering/Advisory Committee Resource Center Satellite Locations 16 Participate in Regional Planning Efforts Facilitate Regional Planning Groups 8

9 Establishing the Resource Center Model in the Community Public/Private Partnerships Cont Partner with other agencies in planning & implementation of special events Identify how to assist community in meeting needs Promote services & partnerships Regular contact with local government 17 Establishing the Resource Center Model in the Community 18 We re Working Together Meetings/Case reviews to establish program functions, develop positive working relationships Division of Family Assistance (Medicaid, Food Stamps) Elderly & Adult Social Workers (Title XX, Title III, APS) HCBC Case Managers Town Welfare Hospitals Nursing Homes/Skilled Care facilities Maintain Established Relationships 9

10 Information & Referral Specialist 19 Responsibilities: Take initial call or greeting; Attempt to understand the consumer s situation through a brief assessment of need; Triage consumer to appropriate staff, or Identify appropriate resources and provide information about each organization or service in order to assist the consumer in making an informed decision; and Follow up with consumer when appropriate. Information & Referral Specialist What Makes This Model Work? The consumer has one-on-one human contact with the Referral Specialist. A rapport is established with the consumer. Response to consumer is done in a professional non-judgmental manner. The consumer is given various approaches to address their questions or problems. 20 Information is given to the consumer in order to enable him/her to feel empowered to make their own decisions. 10

11 Long-Term Support Counselor Responsibilities: 21 Provides counseling to consumers and their families who are at risk of nursing home placement. Provides a comprehensive assessment of need. Communicates urgent situations or unusual circumstances to Long Term Care Nurse. Prescreens Medicaid eligibility. Assists consumers after DFA appointment. Tracks HCBC cases. Provides follow-up services. Long-Term Support Counselor What Makes This Model Work? Personalized service 22 Accessibility of DFA specialist The case management function LTS Counselor and LTC Nurse are located in the same office Support provided by the LTS Counselor Ongoing relationships with community providers Flexibility 11

12 Family Services Specialist (DFA) Responsibilities: Works with SLRCs in four counties, reporting to each SLRC one day per week. Conducts Medicaid financial applications as well as Food Stamp and Medicare Savings Programs during a face-to-face interview. Reviews all verifications required to determine financial eligibility. Collaborates with LTC Counselor. 23 Family Services Specialist (DFA) 24 What Makes This Model Work? SLRC staff have daily access to information relating to status of applications and financial eligibility and immediate notification of decisions. Consumers and families are able to be in a comfortable supportive setting during their eligibility appointment. LTS Counselor can attend any portion of the interview and can assist if additional information is needed. FSS works with LTS Counselor to ensure that applications are completed in a timely manner. 12

13 Long Term Care Nurse Responsibilities: Completes face-to-face clinical assessment for all Medicaid applicants requesting HCBC-ECI or Nursing Facility assistance. Conducts annual redeterminations of all current HCBC-ECI recipients, along with the HCBC Case Managers. Reviews amendments to Service Plans and makes determinations regarding the need for changes. Participates in meetings with other area providers. 25 Long Term Care Nurse What Makes the Model Work? The consumer has an understanding of the process. Sharing an office with the LTS Counselor enables and promotes collaboration. Relationships with other area providers enhance smoother delivery of service for the consumers. Having all the client s information in one place allows for a more positive outcome for the consumer in a shorter amount of time

14 Caregiver Network Purpose Through partnership between local agencies, the SLRC, and caregivers, provide information and support to family caregivers through a network of volunteer caregiver advocates. 27 Caregiver Advocate 28 Functions: Paid caregiver advocate assigns volunteer to family caregiver (referrals received from SLRC staff, community providers, family/friends, or self). Volunteer makes contact and provides information on network activities, such as: 1:1 Supportive Counseling Information & Referral Education and/or Training Caregiver Support Groups Monthly Newsletter Continued. 14

15 Caregiver Advocate Functions: Volunteer makes contact and provides information on network activities, such as (continued): 29 Resource Library Network Quarterly Socials Volunteer Opportunities: Network Leadership Council Public Awareness (Fairs/Presentations) Administrative Support Website Caregiver Advocate Functions: Forwards Caregiver Survival Packet which includes information on caregiving and community services. Refers to or consults with the LTS Counselor for more comprehensive assessment of need and development of a referral plan. Maintains contact with the family caregiver

16 Caregiver Advocate Why This Works Well For Caregivers 31 Family Caregivers benefit from talking with other caregivers (support and ideas on how to provide services and supports to their loved ones). Family Caregivers have different needs at different times (Caregivers can choose 1 or all of the services provided through the Network). Services are ongoing (no time limits or costs). Services provided by an active volunteer network extends resources to family caregivers (ensures sustainability even when funding is in jeopardy). Partnership between providers and consumer advocates result in higher quality of services for family caregivers. ServiceLink Resource Center Has Answers Connections for Independent Living & Healthy Aging Call Toll Free: 1 (866)

17 ServiceLink Resource Center Questions? 33 17

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