Hospitals and Other Critical Pathway Providers

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Informational Overview of Local Contact Agencies in MDS 3.0 Section Q

Source: Technical Assistance Exchange
In October 2010, nursing facilities across the country will begin using a new iteration of the Minimum Data Set, called MDS 3.0. The new version includes a revised Section Q designed to identify residents who may be interested in talking to someone about moving back into the community. For these individuals, nursing facility staff will send referrals to Local Contact Agencies, or LCAs. This document discusses the role of LCAs in the context of the ADRC program.
(Word)
(PDF)
Added April 26, 2010

Overview of Preparing Community-Based Organizations for Successful Health Care Partnerships
Source: The Scan Foundation
The Scan Foundation developed this background brief on how best to build partnerships between community-based long-term services and healthcare systems to improve care transitions and coordination. It focuses on specific opportunities for these partnerships in California.
(External Link) • File type: web
(PDF)
Associated Date: August 2012

Hospital Discharge Planning Presentation and Handouts

Source: Missouri
This is Missouri's portfolio of hospital discharge-planning training including slides, talking points, handouts, and an evaluation form.
(PDF)
Associated Date: April 2012

NY Connects I&A and Options Counseling Referral Protocols with Hospital

Source: New York
These protocols guide the process of referring individuals who are being discharged from inpatient hospital stays and could benefit from NY Connects Information and Assistance and/or Long Term Care Options Counseling.
(Word)
(PDF)
Associated Date: January 2011

Washington State: Hospitals 101

Source: Washington
A guide created by Washington state to help individuals understand important things to know about the process and how to best prepare themselves.
(Powerpoint)
(PDF)
Associated Date: September 2011

Maryland ADRC Transition Planning for Money Follows the Person

Source: Maryland ADRC
This is the Power Point presentation by Stephanie A. Hull and Carole Taliaferro given at the 2010 National Meeting during the session entitled How ADRCs can Support Nursing Facility Transition and Diversion.
(Powerpoint)
(PDF)
Updated November 12, 2010

Oregon Hospital Discharge Feedback Survey

Source: Oregon
This is a hospital discharge feedback form used to evaluate Oregon’s Person-Centered Hospital Discharge Planning Model. The form assesses the patient’s level of understanding and confidence to follow instructions upon discharge from the hospital. The form also assesses the patient’s success in scheduling a follow-up appointment and how well the hospital supports caregivers.
(PDF)
(Word)
Updated April 6, 2010

Planning for Your Discharge - Guide from CMS
Source: CMS
CMS published this guide to help caregivers, patients and staff plan discharges from health care settings.
(Word)
(PDF)
Updated August 27, 2009

Ohio Critical Pathways Flowchart

Source: Ohio ADRC
This flowchart depicts how information about consumers with long-term care needs flows through various critical pathway providers to I & R/A, screening and then eligibility determination.
(PDF)
Updated April 27, 2010

Maryland Critical Pathway Strategic Plan

Source: Maryland
Maryland has provided a draft of their strategic plan to market Maryland Access Point to critical pathways, such as hospitals and social workers.
(Word)
(PDF)
Updated February 10, 2009

New Jersey Hospital At-Risk Criteria Pre-admission Screening - Streamlining Call Presentation - November 9, 2006

Source: New Jersey ADRC
New Jersey presented about their Hospital At-Risk Criteria Pre-admission Screening Pilot on the November 9, 2006 Streamlining Access Peer Workgroup call.
(Powerpoint)
Associated Date: November 09, 2006

MD Howard County Marketing Study Executive Summary

Source: Howard County Office on Aging and ADRC, Maryland
The Howard County Office on Aging in Maryland, and ADRC pilot site, recently completed a marketing study designed to help them meet the needs of the county's aging population. The study, conducted by Kay Loughery at Johns Hopkins University, included a survey of fee-for-service providers in the community. The findings outlined in this Executive Summary will be used to assist Howard County develop ways to build and strengthen relationships with private providers.
(PDF)
(Word)
Updated December 12, 2007

MD Howard County Private Providers Marketing Study Presentation

Source: Howard County Office on Aging and ADRC, Maryland
The Howard County Office on Aging in Maryland, and ADRC pilot site, completed a marketing study designed to help them meet the needs of the county's aging population. This presentation by the researcher, Kay Loughery of Johns Hopkins University, describes the goals and findings of the study, as well as recommendations for Howard County to consider in developing ways to build and strengthen relationships with private providers in the community.
(PDF)
(Powerpoint)
Updated December 12, 2007

Partnering Physicians with Community Organizations
Source: The National Council on Aging Center for Healthy Aging and the Merck Institute of Aging & Health
This toolkit is designed to help physicians collaborate with community-based organizations that serve older adults. It also includes many suggestions and tools useful to organizations collaborating with physicians, including tips on working with physicians, a referral form template, and a sample survey. The National Council on Aging requests that users fill out the following evaluation form in Word format.
(PDF)
Updated June 11, 2010

ADRC December Critical Pathways Call Summary

Source: The Lewin Group, ADRC-TAE
The December 2004 Monthly ADRC call notes summarize information shared by ADRC staff from Indiana, New Hampshire and Wisconsin on how the state ADRC programs have intervened in critical pathways to long term care by focusing on identifying those likely to need long term care.
(Word)
(PDF)
Updated February 10, 2009

Promising Practices: Engaging Physicians in Supporting Family Caregivers
Source: National Association of Area Agencies on Aging
This document lists strategies for involving physicians in referring family caretakers to aging network services. The strategies can be adapted for help in involving physicians in promoting ADRCs as well.
(External Link)
Updated December 12, 2007

Resources from the ADRC-TAE December 2004 Critical Pathways Call

Source: The Lewin Group, ADRC-TAE
This page about the December 2004 Standing Grantee Call on Critical Pathways includes links to all call resources. During the call on December 2, 2004, Indiana, New Hampshire and Wisconsin staff discussed how their programs have intervened in critical pathways to long term care by focusing on identifying those likely to need long term care. Topics included the settings targeted, how to gain buy-in, and defining diversions from institutional care.
(Internal Link)
Associated Date: December 01, 2004

Wisconsin Pre-Admission Consultation Web Page

Source: Department of Health and Family Services, Wisconsin
This web page describes Wisconsin's pre-admission consultation process and provides links to additional materials.
(External Link)
Updated December 11, 2007

Draft Protocols for Receiving Referrals in the SLRC from Hospital

Source: New Hampshire
This document provides the draft protocols for receiving hospital referrals to be used by Resource Center staff.
(Word)
(PDF)
Updated December 21, 2007

ServiceLink RC Referral Check-off Form for Hospital Discharge Planners

Source: New Hampshire
This document is a check-off form for the use of hospital discharge planners in determining whether an individual should be referred to the Resource Center.
(PDF)
(Word)
Updated December 11, 2007

Marketing to Professionals

Source: Minnesota
This marketing fact sheet is directed at providers who may be interested in being listed in the MinnesotaHelp.info database, an online public resource database of human services.
(PDF)
(Word)
Updated December 12, 2007