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					               Indiana Linkage Standard Operating Procedures
                             Table of Contents

211                                                             2
Assisted Living Facilities                                      4
Dental/Medical Assistance                                       6
Disabled Services
 A. Services for Physical Disabilities                          8
 B. Developmental Disabilities (DD) Providers                  10
Emergency/Guardianship
 A. Adult Endangerment Calls                                   12
 B. Immediate Emergency Calls                                  14
Employment                                                     16
Family Caregivers                                              18
Financial Assistance                                           21
Home Care Options                                              24
Home Modifications                                             26
Hospice                                                        28
Housing                                                        30
Information & Referral/Assistance Staffing                     33
IRIS Resource Management                                       35
Legal Advocacy                                                 38
Long Term Care Insurance                                       40
Medicaid
 A. Medicaid Prior Authorization                               42
 B. Medicaid Screening                                         46
Medicare                                                       49
Mental Health Options                                          51
Nursing Facilities
 A. How to Choose a Nursing Home                               53
 B. Emergency Nursing Home Resident Calls                      57
Nutrition                                                      59
Options Counseling                                             61
Physicians                                                     64
Pre-Admission Screening                                        66
Prescriptions                                                  68
Presumptive Eligibility                                        70
Private Case Management                                        72
Senior Centers                                                 74
Short Term Services                                            76
Social Security                                                79
Support Groups                                                 81
Transportation                                                 83
Veterans Benefits                                              85
Waiting List Management                                        87
                                                              211

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        which should be referred to 211.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that an inquiry has been determined as a general inquiry for information that is not
        regarding assistance for the elderly or disabled and therefore would be best assisted through the
        211 call centers. Examples of such inquiries could include, but are not limited to: pregnancy care
        issues, child care centers, children’s programs, art galleries and exhibits, babysitting instruction
        and correctional facility information.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on issues not pertaining to
        the aging and/or disability population, then the Link-Age staff member will refer the individual
        to 211 for assistance.

                                                      2
Step 3: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 4: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 5: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             3
                                            Assisted Living Facilities

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        about assisted living facilities.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as an assisted living inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for assisted living facilities.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on assisted living facilities,
        then Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts.

        Step 3: Link-Age staff must confirm the following, about the individual in need:

                                                      4
   o Medicaid Recipient
   o Medicaid Eligible (If the inquirer is receptive, screen the person for Medicaid using the
     Medicaid screening tool (see the Medicaid Screening SOP), and determine if the person
     is a candidate for Medicaid.)
   o Over-resourced for Medicaid

Step 4: If the individual is a Medicaid recipient, or is eligible for Medicaid, then discuss the
Assisted Living Waiver. Disperse information about assisted living facilities in the area that
accept the Assisted Living Medicaid Waivers and if that is their preferred option, proceed with
in-house procedures for making an Assisted Living Waiver referral. If the individual is not a
Medicaid recipient or candidate, then proceed with dispersing information about all the area
assisted living facilities.

Step 5: Link-Age staff will inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. If
the individual is a walk-in, use the speaker phone option to allow all parties to communicate. It is
best if the referred agency receives information on the concern from the individual. However, if
the person requests that Link-Age supply information to the referred agency, then Link-Age staff
will obtain verbal or written consent from the individual seeking assistance (or that individual’s
Power of Attorney) and then proceed to:
    A. Contact the referred agency for a verbal referral, OR
    B. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
    C. Assist in completing an application if applicable.

Step 6: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 7: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 8: Follow-up for assisted living inquiries may be necessary depending on the situation. If
follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                             5
                                          Assisted Living Facilities
                                          Dental/Medical Assistance

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        dental or medical assistance inquiries.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the inquirer, the nature of the dental or medical need, which may
        include, but is not limited to, any of the following:
            o Dentures
            o Dental Hygiene
            o Oral Surgery
            o Physician Referral
            o Medical Examination

        Step 3: Determine the following information from the inquirer, about the person in need:

                                                      6
   o Demographics (name, address, phone number)
   o Age

Step 4: Research and discuss medical and/or dental assistance options with the inquirer, based on
the information received. Use the IRIS database, training manual or other methods of research to
find applicable programs and services. Search for specific medical and/or dental assistance
programs, such as (in no particular order):
    o Health Clinics
    o Community Clinics
    o Physician Referral Hotlines
    o Dental Programs
    o Affordable Dentures

Step 5: If the inquirer is interested in any of the programs discussed, continue by offering
additional assistance, such as:
       o If a person is interested in Medicaid, complete a Medicaid screening (see the
            Medicaid Screening SOP) to determine possible eligibility. If it looks like Medicaid is
            a probable option for the individual, continue by offering assistance with filling out
            the application. If they would rather fill out the application on their own, then provide
            them with the proper paperwork to apply.
       o Assisting the inquirer with applying for a program, or if assistance is not needed,
            providing the appropriate paperwork to apply for a program, if that paperwork is
            available.
       o If the paperwork to apply is not readily available, offer to contact the appropriate
            agency or person. This can be done by a three-way call, if the inquirer is a caller. If
            the inquirer is a walk-in a call can be made using the speaker phone option so all
            parties are able to communicate. If they do not desire additional assistance, provide
            them with the appropriate information required to make their own contacts.

Step 6: Make sure that all available medical and/or dental options have been exhausted. Confirm
with the inquirer that there is no other need or option to be discussed.

Step 7: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s (the person in need) information is
present, then the database(s) must be updated.

Step 8: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
assisted with applying for a dental program, referred to a health clinic, etc.).

Step 9: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
make sure that the information given was appropriately handled, then proceed with proper
follow-up. This may include, but is not limited to, calls to family members, a hospital, or
individual seeking assistance. If it is evident that the individual received the appropriate
assistance before the termination of the contact, then no further follow-up is required, but
adequate documentation to substantiate no further follow-up is necessary.




                                              7
                                       Services For Physical Disabilities

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking physical disability services or resources for the aged and physically disabled.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a physical disability services inquiry prior to the
        process described here. The Link-Age staff should have knowledge of both public and private
        resources for physical disability services.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information for physical disability
        services, staff needs to identify the specific area, which could include:
            o Home Health Care
            o Therapy
            o Equipment

                                                      8
   o Housing
   o Home Modifications.

Step 3: Link-Age staff will identify possible resources to meet the individual’s need. Link-Age
staff will research programs and information by using the IRIS resource management or resource
information located in the training manual. Such programs for physical disabilities services could
include, but is not limited to:
    o Assistive technology agencies/businesses
    o Nursing facilities and/or other therapy centers
    o Local housing/home modification programs
    o Volunteer programs (camps, religious organizations, colleges/universities) to assist with
        ramps or other home modifications
    o Local disability housing apartments or homes
        Link-Age staff will inform the individual to contact a resource, and if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. If
the inquirer is a walk-in a call can be made using the speaker phone option so all parties are able
to communicate. It is best if the referred agency receives information on the concern from the
individual. However, if the person requests that Link-Age supply information to the referred
agency, then Link-Age staff will obtain verbal or written consent from the individual seeking
assistance (or the individual’s Power of Attorney) and then proceed to:
    A. Contact the referred agency for a verbal referral, OR
    B. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
    C. Assist in completing an application, if applicable.

Step 4: If the individual is seeking home health care services, see the Funding Home Care
Options and/or Medicaid Prior Authorization SOPs. If the individual is not on Medicaid, then
complete the Medicaid screening tool (see the Medicaid Screening SOP) to determine if
Medicaid services could be an option.

Step 5: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 6: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 7: Follow-up for physical disability services inquiries may be necessary depending on the
situation. If follow-up is appropriate to make sure that the concern was resolved, Link-Age staff
needs to pursue proper follow up. This may include, but is not limited to, calls to the initial
contact, individual seeking assistance, family members or the referred agency. If it is evident that
the individual received the appropriate assistance before the termination of the contact, then no
further follow-up is required, but adequate documentation to substantiate no further follow-up is
necessary.




                                             9
                                  Services For Developmental Disabilities


Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________

Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking developmental disability (DD) services.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a DD service inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for DD services.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on developmental
        disabilities services, staff needs to identify the specific area, which could include:
            o Vocational Rehabilitation
            o Residential homes/Group homes
            o Advocacy
            o Respite services

                                                     10
    o   Financial Assistance
    o   Socialization
    o   Habilitation
    o   Life Skills

Step 3: Link-Age staff will identify possible resources to meet the individual’s need. Link-Age
staff will research programs and information by using the IRIS resource management or resource
information located in the training manual. Such programs for developmental disabilities
services could include, but is not limited to:
     o Bureau of Developmental Disabilities
     o Local Developmental Disabilities agencies
     o Local Vocational Rehabilitation services
     o Developmental Disability Field Services
     o Developmental Disability Waiver Ombudsman
     o Disability Resource Networks
     o Goodwill Industries
     Link-Age staff will inform the individual to contact a resource, and if possible or requested,
complete a three-way call with the individual, Link-Age staff and referred agency. If the inquirer
is a walk-in, a call can be made using the speaker phone option so all parties are able to
communicate. It is best if the referred agency receives information on the concern from the
individual. However, if the person requests that Link-Age supply information to the referred
agency, then Link-Age staff will obtain verbal or written consent from the individual seeking
assistance (or the individual’s Power of Attorney) and then proceed to:
     A. Contact the referred agency for a verbal referral, OR
     B. Send a referral to the referred agency by fax, e-mail mail, etc., OR
     C. Assist in completing an application, if applicable.

Step 4: If the individual is seeking a Medicaid Waiver, see the Funding Home Care Options SOP,
and/or refer the individual to the Bureau of Developmental Disabilities Services (BDDS). If the
individual is not on Medicaid, then complete the Medicaid screening tool (see the Medicaid
Screening SOP) to determine if Medicaid services could be an option.

Step 5: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 6: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 7: Follow-up for DD service inquiries may be necessary depending on the situation. If
follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            11
                                       Adult Endangerment/Guardianship

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle adult
        endangerment contacts.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as an adult endangerment situation prior to the
        process described here. Adult endangerment situations are not immediate emergency situations.
        Adult endangerment includes, but is not limited to, wrongful discharge from a nursing home,
        abuse, neglect, self neglect, declining mental status, physical concerns, medical concerns or
        crime victimization.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure. Link-Age is not designed to take the place of the
        police, Adult Protective Services or Emergency Management Services.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the nature of the
        endangerment. Concerns of neglect or abuse can either be suspected or substantiated. It is not the

                                                     12
responsibility of Link-Age staff to substantiate whether a person is abused or neglected, however
it is the responsibility and requirement by law to report any suspected abuse or neglect.

Step 3: Link-Age staff will inform the individual to contact Adult Protective Services, and if
possible, complete a three-way call with the individual, Link-Age staff and Adult Protective
Services. If the inquirer is a walk-in, a call can be made using the speaker phone option so all
parties are able to communicate. It is best if Adult Protective Services hears the information from
the person reporting it, however if the person requests that Link-Age reports to Adult Protective
Services, then Link-Age staff will call Adult Protective Services.
        A. Contact the central Adult Protective Services number, AND
        B. Contact the direct number for the specific Adult Protective Services investigator.

Step 4: If it seems as if the individual in need is not competent to make their own decisions, then
Link-Age staff will seek to discuss Guardianship options with the appropriate contact
individuals. Contact individuals may include Adult Protective Services social worker(s), other
family members or a Power of Attorney. Link-Age staff will follow “in-house” protocol for
completing Guardianship referrals.

Step 5: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s information is present, then the
database(s) must be updated.

Step 6: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the emergency contact.

Step 7 : Follow-up for adult endangerment contacts may be necessary depending on the situation.
If follow-up is appropriate to make sure that the emergency was sufficiently taken care of, then
proceed with proper follow up. This may include, but is not limited to, calls to family members,
a hospital, the police department or Adult Protective Services. If it is evident that the individual
received the appropriate assistance before the termination of the contact, then no further follow-
up is required, but adequate documentation to substantiate no further follow-up is necessary.




                                            13
                                             Immediate Emergency

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        immediate emergency situations.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as an immediate emergency prior to the process
        described here. An immediate emergency is generally described as a circumstance which causes
        the imminent risk of serious harm or death to the individual(s) concerned.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure. Link-Age is not designed to take the place of the
        police, Adult Protective Services or Emergency Management Services.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the individual, the nature of the emergency, the level of risk involved
        and pertinent information about the emergency (location, contact information and who is/are
        involved).

        Step 3: After the determination has been made, follow one of the following procedures:

                                                     14
       A.        For a medical or police emergency, Link-Age staff will call 911 and stay on the
                 line until the natural conclusion of the call. Do not tell the individual to hang
                 up and dial 911; stay on the phone with the person and call 911 for them, or
                 designate another Link-Age staff member to call 911. If there is a doubt about
                 the necessity of medical assistance, still call 911 and let the medical emergency
                 personnel determine the medical necessity.
       B.        If the individual is suicidal, remain on the line (or if the person is a walk-in,
                 remain with the person) and call a local mental health agency, if available. If a
                 mental health agency is not available, then call 911. Remain on the call until it
                 is evident that the individual is receiving the assistance they need.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s information is present, then the
database(s) must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the emergency.

Step 6 : Follow-up for immediate emergency may be necessary depending on the situation. If
follow-up is appropriate to make sure that the emergency was sufficiently taken care of, then
proceed with proper follow up. This may include, but is not limited to, calls to family members,
a hospital, the police department or a mental health organization. If it is evident that the
individual received the appropriate assistance before the termination of the contact, then no
further follow-up is required, but adequate documentation to substantiate no further follow-up is
necessary.




                                            15
                                                      Employment

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        contacts seeking employment services.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as an employment information contact prior to the
        process described here.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the nature of the
        situation or concern. If the situation or concern involves resources or information on
        employment, staff needs to identify the specific area. Such examples could include:
            o Disability Employment services
            o Veteran Employment services
            o Senior Employment Programs


                                                     16
Step 3: Link-Age staff will research programs and information regarding employment services,
based on the specific need determined by probing. Research will be done by using the IRIS
resource management or resource information located in the training manual. Such programs for
employment services could include, but is not limited to:
     o Experience Works
     o Vocational Rehabilitation
     o Sheltered Workshops
     o Work One/Workforce Development
     o Veterans Service Offices
     o Senior Employment Programs (Senior AIDES Programs, Foster Grandparent)
     o Goodwill Industries
     o U.S. Department of Labor
     Link-Age staff will inform the individual to contact a resource, and if possible or requested,
complete a three-way call with the individual, Link-Age staff and referred agency. If the inquirer
is a walk-in, a call can be made using the speaker phone option so all parties are able to
communicate. It is best if the referred agency receives information on the concern from the
individual. However, if the individual requests that Link-Age supply information to the referred
agency, then Link-Age staff will obtain verbal or written consent from the individual seeking
assistance (or the individual’s Power of Attorney) and then proceed to:
        A. Contact the referred agency for a verbal referral, OR
        B. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        C. Assist the individual in completing an application (if Link-Age office has access to
            such material) and send the request to the referred agency by fax, e-mail, mail, hand
            delivery, etc.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for employment services contacts may be necessary depending on the
situation. If follow-up is appropriate to make sure that the concern was resolved, Link-Age staff
needs to pursue proper follow up. This may include, but is not limited to, calls to the initial
contact, family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            17
                                                 Family Caregivers

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles contacts
        involving family caregivers.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that the inquirer is either a family caregiver seeking information about caregiving
        issues, or the Link-Age staff, through the course of conversation, finds out the person is a family
        caregiver and they may benefit from some family caregiver support and counseling.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. After it has been determined that this individual is a family caregiver, determine what
        specific need they might have. Such examples could include:
            o Training opportunities
            o Respite care
            o Support groups

                                                     18
       Link-Age staff is responsible to disseminate accurate information and refer individuals to
appropriate resources or contacts.

Step 3: Link-Age staff will provide the following services to caregivers, as is required by the
Family Caregiver Program:
    A. Information Link-Age staff will provide any information, such as resource guides or
        informational pamphlets, as well as answering questions verbally.
    B. Assistance Link-Age staff will assist any caregiver with issues regarding their
        caregiving duties, whether that be through referrals, helping fill out Medicaid
        applications or mailing appropriate information. Assistance means thorough probing of
        needs and timely follow-through.
    C. Individual Counseling, Support Groups and Training Link-Age staff will alert the
        caregiver of area support groups and training as well as agency training opportunities for
        caregivers. Options counseling will be provided to caregivers, and if the caregiver
        requires professional counseling for mental health issues, then Link-Age staff will refer
        the caregiver to appropriate agencies and resources.
    D. Respite Link-Age staff will confirm with the caregiver that the caregiver is caring for an
        individual age 60 years or older and that their assistance is keeping the individual out of
        a nursing facility. If it seems that a caregiver would be appropriate for respite services,
        then reference agency’s internal protocol for Family Caregiver Program referrals.
    E. Supplemental Services If a caregiver requires additional services that could be met
        through area agencies or resources, then proceed to refer caregiver to area resources. If
        the agency has supplemental service provisions, then reference agency’s internal
        protocol for Family Caregiver Program Supplemental Services referrals.
        Link-Age staff will either take and process a referral for in-agency family caregiver
programs, if applicable, or inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the caller, Link-Age staff and referred agency. If the
individual is a walk-in, then the Link-Age staff may attempt a call using the speaker phone
option so all parties are able to communicate. It is best if the referred agency receives
information on the concern from the individual. However, if the person requests that Link-Age
supply information to the referred agency, then Link-Age staff will obtain verbal or written
consent from the individual seeking assistance (or the individual’s Power of Attorney) and then
proceed to:
        C. Contact the referred agency for a verbal referral, OR
        D. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        E. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for family caregiver inquiries may be necessary depending on the situation. If
follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,

                                            19
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            20
                                               Financial Assistance

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        financial assistance inquiries.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the inquirer, the nature of the financial need.
            o Medical Bills
            o Utility Assistance
            o Rent Assistance
            o Other Financial Assistance


        Step 3: Determine the following information from the inquirer, about the person in need:
            o Demographics (name, address, phone number)

                                                     21
   o Age

Step 4: Research and discuss financial assistance options with the inquirer, based on the
information received. Use the IRIS database and/or resource information located in the training
manual. Search for specific financial assistance programs, such as (in no particular order):
    o Township Trustees
    o Energy Assistance Programs
    o Disease-related Funding Programs (i.e. AIDS fund, Kidney fund)
    o Community Service Groups
    o Medicaid
    o Religious Organizations
    o Other programs not listed

Step 5: If the inquirer is interested in any of the program discussed, continue by offering
additional assistance, such as:
       o If a person is interested in Medicaid, complete the Medicaid screening tool (see the
            Medicaid Screening SOP) to determine possible eligibility. If it looks like Medicaid is
            a probable option for the individual, continue by offering assistance in filling out the
            application. If they would rather fill out the application on their own, then provide
            them with the proper paperwork to apply.
       o Assisting the inquirer with applying for a program, or if assistance is not needed,
            providing the appropriate paperwork to apply for a program, if that paperwork is
            available.
       o If the paperwork to apply is not readily available, offer to contact the appropriate
            agency or person. This can be done by a three-way call, if the inquirer is a caller. If
            the inquirer is a walk-in, a call can be made using the speaker phone option so all
            parties are able to communicate. If they do not desire additional assistance, provide
            them with the appropriate information required to make their own contacts. If the
            person request that Link-Age supply information to the referred agency, then Link-
            Age staff will obtain verbal or written consent from the individual seeking assistance
            (or the individual’s Power of Attorney) and then proceed to:
                A. Contact the referred agency for a verbal referral, OR
                B. Send a referral to the referred agency by fax, e-mail, mail, etc.

Step 6: Make sure that all available financial options have been exhausted. Confirm with the
inquirer that there is no other need or option to be discussed.

Step 7: After the conclusion of the contact, document all information in IRIS. All databases
(such as INSITE) must be referred to and, if the individual’s (the person in need) information is
present, then the database(s) must be updated.

Step 8: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
assisted with applying for Medicaid, assisted with getting financial assistance from the township
trustee, etc.).

Step 9: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
make sure that the information given was appropriately handled, then proceed with proper

                                            22
follow-up. This may include, but is not limited to, calls to family members, the individual
seeking assistance or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            23
                                                Home Care Options

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        contacts seeking resources for home care options for the aged and physically disabled.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a home care options inquiry prior to the process
        described here.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the nature of the
        situation or concern. Such home care options could include, but is not limited to:
            o Homemaker
            o Home Health Aid
            o Respite Care
            o Home Nursing
            o Emergency Response Units

                                                     24
   After the determination of the specific service that is needed, proceed to discuss the different
payment options for home care. Payment options could include the following:
   o Private Pay
   o Reverse Home Mortgages
   o Long Term Care Insurance
   o Home Equity Loans
   o Medicaid Waivers
   o CHOICE (Community and Home Options to Institutional Care for the Elderly and
      Disabled), SSBG (Social Services Block Grant), Title 3 (Older Americans Act)

Step 3: If the individual is interested in such programs as the Medicaid Waivers and/or CHOICE,
SSBG and Title 3, Link-Age staff will proceed with Medicaid screening tool (see the Medicaid
Screening SOP) to determine the possibility of this funding source. Then the Link-Age staff will
follow “in-house” procedures to complete referrals and/or assessments for the appropriate above
mentioned funding sources.
         If the individual is interested in private paying for home care, proceed to discuss the
private case management option (see Private Case Management SOP). If the individual is
interested in Private Case Management, continue with those procedures. If the individual is not
interested in Private Case Management, then proceed to disseminate information on agencies
which could provide the specific service need. Proceed with assisting the individual with referral
information as listed below.
         If the individual is interested in any other funding option, Link-Age staff will research
programs and information by using the IRIS resource management or resource information
located in the training manual. Link-Age staff will inform the individual to contact a resource,
and if possible or requested, complete a three-way call with the individual, Link-Age staff and
referred agency. If the inquirer is a walk-in, a call can be made using the speaker phone option so
all parties are able to communicate. It is best if the referred agency receives information on the
concern from the individual. However if the person requests that Link-Age supply information to
the referred agency, then Link-Age staff will obtain verbal or written consent from the individual
seeking assistance (or the individual’s Power of Attorney) and then proceed to:
     A. Contact the referred agency for a verbal referral, OR
     B. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
     C. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for home care options inquiries may be necessary depending on the situation.
If follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.

                                            25
                                               Home Modifications

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking home modification information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a home modification inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for home modifications.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on home modifications,
        then Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts. Some of the information to probe for during a home
        modification inquiry could include, but is not limited to:
            o Location of the home

                                                     26
   o If the individual owns the home or rents it
   o Ability to purchase home modification, financial status
   o Specific home modification (ramp, door widening, bathroom safety, etc.)

Step 3: Link-Age staff will research programs and information regarding home modifications,
based on the specific need determined by probing. Research will be done by using the IRIS
resource management or resource information located in the training manual. Such programs for
home modification could include, but is not limited to:
    o Carpenters Union
    o Local home supply businesses (lumber yards, home improvement stores, etc.)
    o Local volunteer groups (summer work camps, colleges, religious organizations, etc.)
    o Local handyman businesses/individuals
    o Rebuilding Together
    o Local Housing Authority
        Link-Age staff will inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. If
the person is a walk-in, then the Link-Age staff may attempt a call using the speaker phone
option so that all parties may communicate. It is best if the referred agency receives information
on the concern from the individual. However, if the person requests that Link-Age supply
information to the referred agency, then Link-Age staff will obtain verbal or written consent
from the individual seeking assistance (or the individual’s Power of Attorney) and then proceed
to:
        F. Contact the referred agency for a verbal referral, OR
        G. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        H. Assist in completing an application if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for home modification inquiries may be necessary depending on the situation.
If follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            27
                                                          Hospice

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking hospice information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a hospice inquiry prior to the process described
        here. The Link-Age staff should have knowledge of both public and private resources for
        hospice.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on hospice, then Link-Age
        staff is responsible to disseminate accurate information and refer callers to appropriate resources
        or contacts. Some of the information to gather when probing the inquirer might include the
        following:


                                                     28
   o What sort of hospice service is needed (i.e. home care, support groups, hospice house,
     etc.)?
   o Does the individual have a diagnosis of a terminal illness?

Step 3: Link-Age staff will research programs and information regarding hospice services by
using the IRIS resource management or resource information located in the training manual.
Such programs for hospice could include, but is not limited to:
    o Hospice Foundation of America
    o Local Hospice agencies
    o Hospice Support Groups
         Link-Age staff will inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the caller, Link-Age staff and referred agency. If the
person is a walk-in, then the Link-Age staff may attempt a call using the speaker phone option so
that all parties may communicate. It is best if the referred agency receives information on the
concern from the individual. However, if the person requests that Link-Age supply information
to the referred agency, then Link-Age staff will obtain verbal or written consent from the
individual seeking assistance (or the individual’s Power of Attorney) and then proceed to:
         I. Contact the referred agency for a verbal referral, OR
         J. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
         K. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for hospice inquiries may be necessary depending on the situation. If follow-
up is appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue
proper follow up. This may include, but is not limited to, calls to the initial contact, family
members or the referred agency. If it is evident that the individual received the appropriate
assistance before the termination of the contact, then no further follow-up is required, but
adequate documentation to substantiate no further follow-up is necessary.




                                            29
                                                          Housing

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking housing information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a housing inquiry prior to the process described
        here. The Link-Age staff should have knowledge of both public and private resources for
        housing.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on housing, then Link-Age
        staff is responsible to disseminate accurate information and refer individuals to appropriate
        resources or contacts. Some of the information to probe for during a housing inquiry could
        include, but is not limited to:


                                                     30
   o Financial Assistance (subsidized rentals, low income rentals, subsidized home
     purchasing, etc.)
   o Disability Accessible Housing
   o Emergency Housing
   o Senior Housing Options (senior living communities, senior apartments, assisted living
     facilities, adult foster care, etc.)

Step 3: Link-Age staff will research programs and information regarding housing options, based
on the specific need determined by probing. Research will be done by using the IRIS resource
management or resource information located in the training manual. Such programs for housing
could include, but is not limited to:
    o U.S. Department of Housing and Urban Development
    o Indiana Housing and Community Development Authority at (800)-872-0371.
    o Section 8 Housing
    o Local assisted living facilities (See Assisted Living SOP)
    o Local senior living communities
    o Local senior apartments
    o Local Housing Authority
    o Local real estate agencies
    o Local subsidized housing programs
    o Local disability accessible housing options
    o Local nursing facilities (See How to Choose a Nursing Home and/or Pre-Admission
        Screening SOPs)
    o Local homeless shelters
    o Local emergency shelters
        Link-Age staff will inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. If
the person is a walk-in, then the Link-Age staff may attempt a call using the speaker phone
option so that all parties may communicate. It is best if the referred agency receives information
on the concern from the individual. However, if the person requests that Link-Age supply
information to the referred agency, then Link-Age staff will obtain a verbal or written consent
from the individual seeking assistance (or the individual’s Power of Attorney) and then proceed
to:
        L. Contact the referred agency for a verbal referral, OR
        M. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        N. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for housing inquiries may be necessary depending on the situation. If follow-
up is appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue
proper follow up. This may include, but is not limited to, calls to the initial contact, family

                                            31
members or the referred agency. If it is evident that the individual received the appropriate
assistance before the termination of the contact, then no further follow-up is required, but
adequate documentation to substantiate no further follow-up is necessary.




                                            32
                              Information & Referral/Assistance Staffing

Control Information

                Revision:                     001A
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide the staffing capacity and classification for Area
        Agencies on Aging Information & Referral/Assistance Departments.

Scope

        This procedure is applicable to all AAA’s across the state of Indiana.

Responsibility

        All AAA’s are responsible for complying with the staffing capacity and classification which will
        be monitored by the Division on Aging.

Supporting Documentation

        IRis call volume and capacity reports and daily timesheets.

Procedure

        Step 1: Identify the call volume per Area Agency on Aging.

        Step 2: Identify the call volume category.

        Step 3: Hire adequate staffing based on the following:

        Agency Size                    Call Volume           FTEs
                                 Per Day      Per Year
        Small                    30           6,300          1

                                                     33
                       45             9,450          1.5
                       60             12,600         2
Medium                 75             15,750         2.5
                       90             18,800         3
                       105            21,950         3.5
Large                  120            28,250         4
                       135            31,400         4.5
                       150            34,055         5

Note: Holiday and staff time off has been taken into consideration when computing yearly call
volume.

Step 4: Hire adequate staffing classification based on the volume category.

        I & R Specialist I is AIRS Certified
        I & R Specialist II is AIRS Certified and trained as a Benefit Counselor
        Resource Specialist is AIRS Certified in CRS




                                            34
                                        IRIS Resource Management

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to manage
        resource information in IRIS.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. The Link-Age
        website has merged data from Link-Age sites which is powered by IRIS for the Web. The
        establishment of a complete database requires time and staff and it is with this understanding that
        this procedure is written with the viewpoint that completion of these steps may vary in length of
        time from one agency to the next. This procedure assumes that each Link-Age site has at least a
        partially developed IRIS resource database, with the goal of a completed database by the time the
        site is applying for AIRS accreditation.

Responsibility

        Link-Age staff who manages the IRIS resource management.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: As all Link-Age sites will seek AIRS accreditation at some future date, the Link-Age site
        must be actively working toward completion of all of the following steps, as stated in the AIRS
        Accreditation Application:
        Step 2: Inclusion/Exclusion Criteria: “The (Link-Age site) shall develop criteria for inclusion
        or exclusion of agencies and programs in the resource database. These criteria shall be uniformly


                                                    35
applied and published so that staff and the public will be aware of the scope and limitations of
the database.”

Step 3: Data Elements: “A standardized profile shall be developed for each organization that is
part of the local community service delivery system or other geographic area or service sector
covered by the (Link-Age site).”
        Each site’s database must complete all of the following data elements (however, if the
element is not applicable to a program or agency, i.e. an agency does not have a website, then the
site will not include this information, however it is to be understood that if the agency does have
any of the items listed below, all of that information must be included in the record), as is listed
for Indiana 211 and AIRS Standards:
             o Unique record ID
             o Legal name of organizations and AKAs
             o Program name
             o Street and mailing addresses
             o Phone
             o Fax
             o TTY
             o E-mail
             o Web
             o Hours (including the time zones, using ET and CT, for Eastern and Central Time
                 Zones)
             o Services provided (usually in short narrative form)
             o Target populations served
             o Eligibility requirements and documents
             o Geographic area served
             o Application process
             o Languages other than English
             o Legal status
             o Fee structure
             o Payment method
             o Name & title of director
             o Date information was verified

Step 4: Classification System/Taxonomy: “The (Link-Age site) shall use a standard service
classification system to facilitate retrieval of community resource information, to increase the
reliability of planning data, to make evaluation processes consistent and reliable, and to facilitate
national comparisons of data.”
The following points are to be standard for each Link-Age site:
    o All programs must be assigned keywords approved on the Indiana 211 Standard Keyword
         list.
    o Local keywords may be used, though this is discouraged. If a program is assigned a local
         keyword, it must also have a Standard Keyword assigned.
    o All programs must be assigned using the Standard Keywords prior to the merger of data
         onto the Link-Age website.
    o All programs must be assigned the appropriate county keywords. County keywords are
         expected to be assigned for each site’s area of service. If a program is statewide or
         national, the site is expected to assign all of its service area counties only.

                                             36
   o All programs must also be assigned Taxonomy. Though no Standard Taxonomy list has
     been approved as of yet, it is expected that all Link-Age sites would follow the same
     standards of application once a Standard Taxonomy list is adopted.

Step 5: Database Maintenance: “ The resource database shall be computerized, maintained by
trained resource staff and updated through continual revision at intervals sufficiently frequent to
ensure accuracy of information and comprehensiveness of its contents.”
    o All Link-Age sites are required to complete, at a minimum, annual updates. More
        frequent updates are greatly encouraged.

All quotes are taken from the AIRS Accreditation Application, Area II: Resource Database,
Components A, B, D, E.




                                             37
                                                   Legal/Advocacy

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking legal assistance information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a legal advocacy inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for legal assistance.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on legal assistance, then
        Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts. Some of the information that may need to be collected prior to
        referring the individual to an agency or program may include the following:
            o Age of the inquirer

                                                     38
   o Specific legal issue

Step 3: Link-Age staff will research programs and information regarding Legal Advocacy by
using the IRIS resource management or resource information located in the training manual.
Such programs for Legal Advocacy could include, but is not limited to:
     o Indiana Legal Services
     o AARP Legal Services Network
     o Lawyer Referral Services
     o National Senior Citizens Law Center at (202) 887-5280.
     o Local Legal Clinics and Pro Bono Services
     o Bar Associations
     Link-Age staff will inform the individual to contact a resource, and, if possible or requested,
complete a three-way call with the individual, Link-Age staff and referred agency. If the person
is a walk-in, then the Link-Age staff may attempt a call using the speaker phone option so that all
parties may communicate. It is best if the referred agency receives information on the concern
from the individual. However, if the person requests that Link-Age supply information to the
referred agency, then Link-Age staff will obtain a verbal or written consent from the individual
seeking assistance (or the individual’s Power of Attorney) and then proceed to:
        O. Contact the referred agency for a verbal referral, OR
        P. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        Q. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             39
                                         Long Term Care Insurance

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking long term care insurance information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a long term insurance inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for long term insurance.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on long term insurance,
        then Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts.




                                                     40
Step 3: Link-Age staff will research programs and information regarding Long Term Care
Insurance by using the IRIS resource management or resource information located in the training
manual. Such programs for Long Term Care Insurance could include, but is not limited to:
     o SHIP, State Health Insurance Assistance Program
     o Indiana Department of Insurance at (317) 232-5695.
     o Local Elder Law Attorneys
     o Indiana Long Term Care Partnership, for information call (800) 452-4800.
     o Other local agencies or resources that assist with long term health insurance issues.
     Link-Age staff will inform the individual to contact a resource, and, if possible or requested,
complete a three-way call with the individual, Link-Age staff and referred agency. If the person
is a walk-in, then the Link-Age staff may attempt a call using the speaker phone option so that all
parties may communicate. It is best if the referred agency receives information on the concern
from the individual. However, if the person requests that Link-Age supply information to the
referred agency, then Link-Age staff will obtain verbal or written consent from the individual
seeking assistance (or the individual’s Power of Attorney) and then proceed to:
        R. Contact the referred agency for a verbal referral, OR
        S. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        T. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             41
                                       Medicaid Prior Authorization

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        inquiries or possible eligible persons for Medicaid Prior Authorization.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. It is understood that
        this procedure is for inquiries which have either asked specifically about the Medicaid Prior
        Authorization program or individuals who have been through options counseling with a Link-
        Age staff member. That individual, through the course of options counseling, was found to be a
        strong candidate for possible Medicaid Prior Authorization services.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine the following information from the inquirer, about the person in need:
            o Demographics (name, address, phone number)
            o Age




                                                     42
Step 3: Determine, from the inquirer, if the person in need is on Medicaid or if they are close to
qualifying for Medicaid. If the person is on Medicaid, continue to the fourth step. If the person is
close to qualifying for Medicaid, proceed by completing the Medicaid screening tool (see the
Medicaid Screening SOP) and assisting them with the Medicaid application, if they so desire.

Step 4: Explain Medicaid Prior Authorization (PA) by using the following definition:
    o The PA objective is to serve as a utilization management measure allowing payment only
        for those treatments and/or services that are medically necessary, appropriate, and cost-
        effective, and to reduce overutilizing and/or abuse of specified services.

Step 5: Discussion of services. Determine the specific need of the individual and
proceed by discussing the Prior Authorization services and their requirements:
    Home Health Services
    o Registered Nurse
    o Licensed Practical Nurse
    o Home Health Aid
    Home Health Service Requirements
    o All home health services require PA except when ordered by physician prior to hospital
       discharge and do not exceed 120 hours within 30 days of discharge.
    o Documented acute medical needs.
    o Prescribed or ordered in writing by a physician.
    o Provided in accordance with a written plan of treatment developed by the physician.
    o Intermittent or part-time except for ventilator dependent patients with a plan of home
       health care developed.
    o Deemed medically reasonable and necessary.
    o Deemed less expensive than any alternate modes of care.
    o Provided only to members who are medically confined to the home.
    o Related nursing care (homemaker, chore, sitter/companion) are not covered.
    Therapy Services
    o Occupational Therapy
    o Physical Therapy
    o Speech Therapy
    o Respiratory Therapy
    Therapy Service Requirements
    o All therapy services require PA except when ordered by a phsyician prior to hospital
       discharge and do not exceed 120 hours within 30 days of discharge.
    o Written evidence of physican involvement and personal patient evaluation to document
       acute medical needs.
    o Current treatement plan and progress notes as to the necessity and effectiveness of
       therapy.
    o Qualified therapist of qualified assistant under direct supervision of therapist must
       provide therapy.
    o Therapy must be of such a level of compleity and sophistication and the condition of the
       recipient must be such that the judment, knowledge, and skills of a qualified therapist are
       required.
    o Only for medically necessary therapy.
    o Therapy for rehabilitative services is covered no longer than 2 years unless there is a
       significant change in medical condition requiring longer therapy.

                                             43
o  Can be authorized longer for children under age 18 on a case-by-case basis.
o  Respiratory therapy can be authorized longer on a case-by-case basis.
o  Maintenance therapy is not covered.
o  Ongoing evaluations are part of the therapy program.
o  An hour must include a minimum of 45 minutes of direct care with the balance spent in
   related services.
o Not approved for more than one hour per day per type of therapy.
o Cannot duplicate other services.
Medical Supplies Services
o Incontinence supplies (underpads, incontinent briefs and liners, diapers, disposable
   diapers)
o Possible other medical supplies, see 405 IAC 5-19.
Medical Supplies Service Requirements
o Incontinence supplies require PA for children older than 3 years.
o Not available for children younger than 3 years.
o Based on documented medical necessity.
o Limited to $1,950 per rolling 12-month period.
Durable Medical Equipment Services
o Wheelchairs
o Communications Devices
o Possible other equipment, see 405 IAC 5-19.
Durable Medical Equipment Requirements
o PA is required for all rented or purchased equipment except: cervical collars, back
   supportive devices such as corsets, hernia trusses, parenteral infusion pumps when used
   in conjunction with parenteral hyperalimentation including central venous catheters,
   eyeglasses, extensive list of items not requiring PA in Indiana Health Coverage Programs
   Provider Manual.
o Medical clearance form must be submitted with request to justify medical necessity.
o All repairs of purchased equipment require PA.
o Requests reviewed on a case-by-case basis.
o Must be medically necessary for the treatment of an illness or injury or to improve the
   functioning of a body member.
o Must be adequate for the medical need; items with unnecessary convenience or luxury
   features are not authorized.
o Anticipated period of need, plus the cost of the item is considered in determining whether
   the item is rented or purchased.
Health Care Transportation
PA is required for the following:
o Trips exceeding 20 one-way trips per rolling 12-month period, except emergency
   ambulance services, transportation to or from a hospital for the purpose of admission or
   discharge, or patients on dialysis.
o Trips that are 50 miles or more one-way.
o Transportation to or from an out-of-state non-designated area.
o Airline or air ambulance services by a provider located out of state in a non-designated
   area.
o In-state train or bus services.
o Family member services.
PA Resources

                                       44
   o Indiana Health Coverage Programs Provider Manual, Chapter 6: Prior Authorization. See
     website: www.indianamedicaid.com
   o Indiana Administrative Code 405 IAC Article 5. See website at
     www.in.gov/legislative/ic/code

Step 6: After the appropriate services and requirements have been discussed, and the inquirer is
interested in progressing further, use the following website:
www.in.gov./isdh/regsvcs/acc/hhadir/index.htm to provide a provider list for Prior
Authorization. This list includes all the area providers that offer home health services; the
providers that are Medicaid certified are able to provide Medicaid Prior Authorization. Instruct
the inquirer to contact any of the providers on the list and explain their desire and need for Prior
Authorization services. Explain that Link-Age does not administer this program, but is willing to
assist the individual in any way possible.

Step 7: Confirm with the inquirer that there is no further need prior to terminating the contact.

Step 8: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s (the person in need) information is
present, then the database(s) must be updated.

Step 9: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
assisted with Medicaid PA process, etc.)

Step 10: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
make sure that the information given was appropriately handled, then proceed with proper
follow-up. This may include, but is not limited to, calls to family members, the individual
seeking assistance or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                             45
                                                Medicaid Screening

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        inquiries for possible Medicaid eligible persons.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. Within the context
        of assisting individuals, Link-Age staff must inquire about Medicaid status. If the individual in
        need is not on Medicaid, however they may be eligible and benefit from its services, proceed by
        using the Medicaid Screening Worksheet. Medicaid Screening can be completed at any time
        while discussing a variety of different options with the individual. This procedure assumes that
        the individual in need is interested in Medicaid and wants to proceed with a screening to
        determine further possible eligibility.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: To work the way through the worksheet, income, asset and other information must be
        gathered to make a feasible recommendation. Obtain a written or verbal consent that the release


                                                     46
of this information to the Link-Age staff meets with their approval. Proceed with the gathering of
the following information:
     Income
           I. Social Security
          II. Social Security Disability
         III. Pension
         IV. Veteran’s Benefits.
          V. Gather the last employer’s information, the individual may have benefits that are
              available that aren’t know about.
         VI. Does the individual have direct deposit?
     Assets
           I. Checking
          II. Savings
         III. CD
         IV. Other (Stocks, bonds, cash on hand, safety deposit boxes, land or buildings that they
              are not living in, etc.)
          V. Own a home? (The home is exempt until owner is no longer living there)
         VI. Given away money in the past 5 years?
        VII. Bank Names
     Other Medical Insurance
         I. Name
        II. Address
       III. Cost
       IV. Coverage
     Life Insurance Company
         I. Name
        II. Address
       III. Cost
       IV. Value
        V. Funeral Trust Name
     Other Information
         I. Pharmacy
        II. Doctors
       III. Hospitals
       IV. Medicare In-Home
        V. Emergency Response System/O2/Rentals
       VI. Highest Grade Completed in school
     Car
         I. Value/Cost
        II. Car Insurance

Step 3: Take the information given and compare to the current Medicaid Guidelines for the
appropriate group (i.e. Medicaid for Seniors and Disabled).

Step 4: If it looks like the individual would qualify for Medicaid services,
instruct the individual to apply. Offer to assist the individual with the
application, however if no assistance is desired, then give the individual the


                                             47
application (if the individual walked-in) or mail the application (if the individual
called). .

Step 5: Confirm with the inquirer that there is no further need prior to terminating the contact.

Step 6: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s (the person in need) information is
present, then the database(s) must be updated.

Step 7: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
assisted with applying for Medicaid, etc.).

Step 8: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
make sure that the information given was appropriately handled, then proceed with proper
follow-up. This may include, but is not limited to, calls to family members, the individual
seeking assistance or a Power of Attorney. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                             48
                                                          Medicare

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking Medicare information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a Medicare inquiry prior to the process described
        here.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on Medicare, then Link-
        Age staff is responsible to disseminate accurate information and refer callers to appropriate
        resources or contacts.




                                                     49
Step 3: Link-Age staff will research programs and information regarding their Medicare need by
using the IRIS resource management or resource information located in the training manual.
Such programs for Medicare inquiries could include, but is not limited to:
     o State Health Insurance Assistance Program (SHIP)
     o The Medicare website: www.Medicare.gov or Toll Free number at (800)-MEDICARE.
     o Medicare Ombudsman at (800) 633-4227.
     o Social Security Administration
     o Other local programs that assist with Medicare issues and questions.
     Link-Age staff will inform the individual to contact a resource, and, if possible or requested,
complete a three-way call with the individual, Link-Age staff and referred agency. If the person
is a walk-in, then the Link-Age staff may attempt a call using the speaker phone option so that all
parties can communicate. It is best if the referred agency receives information on the concern
from the caller. However, if the caller requests that Link-Age supply information to the referred
agency, then Link-Age staff will obtain a verbal or written consent from the individual seeking
assistance (or the individual’s Power of Attorney) and then proceed to:
        U. Contact the referred agency for a verbal referral, OR
        V. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        W. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             50
                                             Mental Health Options

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking mental health information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a mental health inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for mental health options.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on mental health, then
        Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts. Link-Age staff will probe the individual to determine the
        specific mental health need, which could include, but is not limited to, the following:
            o Counseling services

                                                     51
   o Psychiatric treatment
   o Hospitalization
   o Semi-independent living assistance

Step 3: Link-Age staff will research programs and information regarding their specific need by
using the IRIS resource management or resource information located in the training manual.
Such programs for mental health options could include, but is not limited to:
    o Mental Health Association
    o Mental Health Ombudsman
    o Local inpatient & outpatient centers
    o Local hospitals
    o Mental Health Organizations
    o Counseling Centers
    o Local Psychiatrists and/or psychologists
    Link-Age staff will inform the individual to contact the resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. If
the person is a walk-in, then the Link-Age staff may attempt a call using the speaker phone
option so that all parties may communicate. It is best if the referred agency receives information
on the concern from the person. However, if the individual requests that Link-Age supply
information to the referred agency, then Link-Age staff will obtain verbal or written consent
from the individual seeking assistance (or the individual’s Power of Attorney) and then proceed
to:
        X. Contact the referred agency for a verbal referral, OR
        Y. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        Z. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             52
                                       How to Choose a Nursing Home

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to respond to
        this inquiry “How to Choose a Nursing Home”.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. Options counseling
        (see the Options Counseling SOP) is to be administered at the beginning of the inquiry prior to
        answering questions in regard to nursing facility placement.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the individual , the nature of the need.

        Step 3: After the determination has been made, utilizing the hand book, “How to Choose a
        Nursing Home” recommend the following:
                A.      Make a List (this would include any facility of interest).
                B.      Discuss options with friends, clergy, those you trust who might have information
                        or experience with the facilities listed.

                                                     53
               C.     Plan to visit various facilities in person. During the visit speak with staff and
                      residents about the facility; make the visit unannounced. View the results of the
                      latest survey conducted by the Indiana State Department of Health. This report is
                      to be accessible to residents and visitors. Also, use your five senses. How does
                      the facility smell? Are there loud noises? Is the facility clean? Are residents
                      participating in activities? Do the staff members speak to each other and to
                      residents in a kind manner? If the visit is during meal time, does the food smell
                      good? Is the menu easy to follow? Use a checklist to document and note specifics
                      about each facility visited.
               D.     Understand Finances How will you pay for the care? (If the answer indicates the
                      need, Medicaid screening should be completed at this time. Medicaid Packet
                      attached.) Ask for a copy of the facility’s admission agreement and read it
                      thoroughly. You may ask the admissions contact or administrator to clarify any
                      question.
               E.     Further resources to assist in choosing a nursing home include: Health Care
                      Financing Administration: “Your Guide to Choosing a Nursing Home”,
                      publication No. 02174; Health Care Financing Administration: “Nursing Homes-
                      Basic Information on How to Choose”, publication No. 10121 (Order either
                      publication by calling 1-800-633-4227) Also, contact your local Ombudsman and
                      the Area Agency on Aging.
               F.     Making a Decision When making this decision, it is recommended that the
                      prospective resident be included in this decision since he/she is most affected by
                      this move. Also keep in mind that if a decision is made that is unsatisfactory, you
                      can always look around for a facility that is better suited to the resident.
               G.     Making the nursing home decision can be difficult and stressful and sometimes
                      seems overwhelming. Understanding options and learning as much as possible
                      will help make the best possible decision.
               H.     Inform the contact that in the event this decision is made, a screening process
                      (PAS) is mandatory in the state of Indiana. Give contact information to inquirer to
                      facilitate the process.
               I.     Offer to mail a Nursing Home Question and Check List (attached).
               J.     Offer to mail information about surveys from various web sites.

       Step 4: After the conclusion of the contact, document all information in IRIS and mail any
       requested information.



                       NURSING HOME QUESTIONS AND CHECKLIST

General
*How long have the current owner, administrator and director of nursing been with the facility?
*Has there been stability at these levels?
*Is there a written statement of resident’s rights clearly posted?
*Are visiting hours convenient for residents and visitors?
*Who owns the nursing home and how does that person or organization get consumer input?

Medical Care

                                                   54
*Is the home reasonably close to a hospital offering emergency services?
*How does the home assure regular medical attention?
*How often do physicians visit?
*Is transportation provided for medical appointments outside the building?
*Is there on site physical and occupational therapy?
*What is the turnover rate for nurses and nursing assistants?
*What is the staff to resident ratio?
*Are residents able to choose their own physician?

Resident Rooms
*In shared rooms, does each resident have private space, room for individual belongings and space for
visitors? How many residents share a bathroom?
*How are room changes and roommate concerns addressed?
*Is there locked storage available?
*Roommate privacy curtains?
*Are furnishings adequate?
*Do staff knock on the door and wait for an answer before entering rooms?

Environment
*Are there individual room temperature controls?
*Is there are conditioning?
*Are there designated smoking areas and times?
*Smoke free?
*Are exits clearly marked?
*Are the grounds well lit?
*Are special considerations taken in the design of outside areas for residents with memory loss or
wandering issues?

Dining
*Are there interesting menu choices?
*Are there posted substitutions?
*Can residents choose seating?
*Are guests allowed?
*Are residents permitted to have food/snacks in their room?
*How are the dining rooms staffed?
*What are meal times?
*Do meals look appetizing?
*Is food served at the proper temperature?

Staffing
*How many residents are assigned per nursing assistant?
*Is that different on other shifts?
*How are new staff screened and trained?
*Is there on-going training for all staff?
*Is there a volunteer program?
*Adequate social services, activities and therapy staff?
*Do staff members who genuine interest?
*Do they take time to visit with residents?

                                                   55
Residents
*Do residents appear happy and content?
*Is there fellowship among residents?
*Is there a resident council?
*Is there a resident newsletter?
*Is there a family council?
*Are residents involved in the planning of menus and activities?
*How are residents notified and invited to care plan conferences?
*Are residents well groomed and nicely dressed?
*Do residents speak favorably of the home?

   These are just a few of the questions that you should keep in mind and ask yourself when touring or
determining which facility you will choose. Consult friends and others in the community for feedback
on their experiences. With this information you will be able to make an informed decision on which
facility best suits your or your family member’s needs.




                                                  56
                             Emergency Nursing Home Resident Contacts

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        emergency nursing home resident contacts.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as an emergency nursing home resident contact. All
        emergency nursing home resident contacts will be handled by the Ombudsman, however if a
        local Ombudsman is unavailable and an individual will not wait or leave a voice mail, this
        document is meant to give guidelines on how to handle these contacts.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure. Link-Age is not designed to take the place of the
        police, Adult Protective Services or Emergency Management Services.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: First make the determination that this is a nursing home resident with an emergency
        concern and determine that there is no local Ombudsman available to assist the client.

        Step 2: Determine the nature of the emergency. If the emergency is in regards to the following,
        use this information to assist them:


                                                   57
       A. If the client is in a hospital about to be discharged to a nursing home, the resident or
          responsible party has the right to refuse a particular nursing home. They don’t have to
          accept a particular nursing home, even if it is the only nursing home that will accept
          them. However, they may have to pay for the additional day(s) in the hospital out of
          pocket until an “acceptable” nursing home is found.
       B. If the resident is being discharged from a nursing home, they have the right to a 30
          day discharge notice, with the right to appeal the notice within the first 10 days. They
          can call the Indiana State Department of Health at (317) 233-7794 for more
          information about this.
               1. If the resident has been in the facility for less than 30 days, then the facility
                   can discharge the resident at will.
               2. If the facility sent the resident to a hospital and won’t accept them back, the
                   30 day notice doesn’t apply if the facility is less than 90% occupied.

Step 3: If the emergency is not in regards to any of the above scenarios, then it is best to refer the
resident to someone else. Referrals may be made to the following:
        o State Ombudsman at (317) 232-7134
        o Indiana State Department of Health at (800) 246-8909
        o Adult Protective Services

Step 4: If the resident was not able to reach any of the parties mentioned above and assistance is
still needed, then direct the resident to file a police report.

Step 5: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s information is present, then the
database(s) must be updated.

Step 6 : If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the emergency contact.

Step 7: Follow-up for emergency nursing home resident contacts may be necessary depending on
the situation. If follow-up is appropriate to make sure that the emergency was sufficiently taken
care of, then proceed with proper follow up. This may include, but is not limited to, calls to
family members, a hospital, the police department or a mental health organization. If it is evident
that the individual received the appropriate assistance before the termination of the contact, then
no further follow-up is required, but adequate documentation to substantiate no further follow-up
is necessary.




                                              58
                                                          Nutrition

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        nutrition inquiries.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the inquirer, the nature of the nutritional need.
            o Not complying with a special diet
            o Lack of available food
            o Not able to prepare a meal
            o Other nutritional needs

        Step 3: Determine the following information from the inquirer, about the person in need:
            o Demographics (name, address, phone number)
            o Age

                                                     59
   o Mobility (i.e. ability to drive)

Step 4: Research and discuss nutrition options with the inquirer, based on the information
received. Use the IRIS database or resource material located in the training manual to find
applicable programs and services. Search for specific nutrition programs, such as (in no
particular order):
    o Soup Kitchens
    o Food Pantries
    o Food Banks
    o Home Delivered Meals
    o Nutrition Sites
    o Food Vouchers
    o Food Stamps

Step 5: If the inquirer is interested in any of the program discussed, continue by offering
additional assistance, such as:
    o Assisting the inquirer with applying for a program, or if assistance is not needed,
       providing the appropriate paperwork to apply for a program, if that paperwork is
       available.
    o If the paperwork to apply is not readily available, offer to contact the appropriate agency
       or person. Make sure to obtain a verbal or written consent from the individual seeking
       assistance or that person’s Power of Attorney to share information with any referred
       agency/program. To contact the agency or person, make a three-way call, if the inquirer
       is a caller. If the inquirer is a walk-in a call using the speaker phone option can be made
       so that all parties can communicate. If they do not desire additional assistance, provide
       them with the appropriate information required to make their own contacts.

Step 6: Make sure that all available nutrition options have been exhausted. Confirm with the
inquirer that there is no other need or option to be discussed.

Step 7: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s (the person in need) information is
present, then the database(s) must be updated.

Step 8: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
assisted with applying for food stamps, assisted with getting home delivered meals started, etc.)

Step 9: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
make sure that the information given was appropriately handled, then proceed with proper
follow-up. This may include, but is not limited to, calls to family members, the individual
seeking assistance or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            60
                                                Options Counseling

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to administer
        options counseling.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. It is understood that
        prior to the implementation of this procedure, the nature of the contact has already been
        determined as a prime options counseling situation. Options counseling is not to be implemented
        for contacts who are only asking for an address or phone number and request no further
        assistance. It is also understood that individuals are not always aware of all of their needs;
        therefore Link-Age staff will be thorough in discussing options with each contact. Options
        counseling is to be administered in the following contact situations:
            o Initial Pre-Admissions Screening contacts (excluding nursing facility transfer calls).
            o Any other contact where education on options is initiated or deemed appropriate (which
                could include, but is not limited to, inquiries about in-home services or assisted living).

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.


                                                     61
Step 2: Determine, from the inquirer, the purpose of the contact. Assess the situation, asking such
questions as:
    o What kind of help are you looking for?
    o What do you say is the underlying problem?

Step 3: Probe further to find out all the needs of the individual. Ask the inquirer the following
about the individual in need, this information can help find specific programs that meet the needs
mentioned.
    o Demographics (name, address, phone number)
    o Location (home, facility, hospital, etc.)
    o Age
    o Physical Disabilities
    o Mental Disabilities
    o Support System (family, friends, neighbors, etc.)

Step 4: After a good understanding of the needs involved, discuss the following options and if
that option is applicable for the individual in need, proceed with the following step(s):
        A. In-Home Services
                1. Including, but not limited to: Home Health Aide, Homemaker, Bath Aide,
                    Attendant Care Aide, Friendly Companion and Home Care Nurse. See the
                    Funding Home Care Options SOP to proceed with any one of these options.
        B. Nutrition
                1. Including, but not limited to: congregate meal sites, food pantries, food banks,
                    food vouchers, food stamps and home delivered meals. See the Nutrition SOP
                    to proceed with any one of these options.
        C. Housing/Shelter
                1. Including, but not limited to: homeless shelters, low rental apartments,
                    disabled apartments, subsidized apartments, Section 8, home repair and
                    weatherization. See the Housing SOP to proceed with any one of these
                    options.
        D. Adult Day Services
                1. See the Funding Home Care Options SOP to proceed with this option.
        E. Assisted Living
                1. See the Assisted Living Facilities SOP to proceed with this option.


       F. Financial Assistance
             1. Including, but not limited to: township trustees, religious organizations,
                 energy assistance programs, disease-related funding programs, community
                 service groups and Medicaid. See the Financial Assistance SOP to proceed
                 with this option.
       G. Respite Services
             1. See Funding Home Care Options and Family Caregivers SOPs to proceed
                 with this option.
       H. Transportation
             1. Including, but not limited to: senior transportation program, transportation
                 expense assistance, medical transportation, wheelchair transportation and
                 mass transportation. See the Transportation SOP to proceed with this option.

                                            62
       I. Legal Services
             1. Including, but not limited to, senior legal programs, legal clinics, guardianship
                 services and power of attorney. See the Legal Advocacy SOP to proceed with
                 this option.
       J. Mental Health Services
             1. Including, but not limited to, counseling services, residential services, in-
                 patient services, out-patient services, mental health associations, support
                 groups and therapies. See the Mental Health Options SOP to proceed with this
                 option.
       K. Health/Dental Services
             1. Including, but not limited to, community clinics, dental programs, physician
                 referral hotlines and dental clinics. See the Dental/Medical Assistance SOP to
                 proceed with this option.
       L. Education
             1. Including, but not limited to, GED programs, continuing education programs,
                 senior education programs, language programs and literacy programs. Assist
                 as needed to link the individual with any of the listed options.
       M. Recreation
             1. Including, but not limited to, senior centers, senior programs, developmental
                 disability recreational programs, sports and fitness programs, arts programs.
                 See the Senior Centers SOP and/or assist as needed to link the individual with
                 any of the listed options.
       N. Nursing Facility Placement
             1. See the How to Choose a Nursing Home SOP to proceed with this option.

Step 5: After the conclusion of the contact, document all information in IRIS. All databases (such
as INSITE) must be referred to and, if the individual’s information is present, then the
database(s) must be updated.

Step 6: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified about the action taken (i.e.
placed on waiting lists, made a referral, made a Pre-Admissions Screening referral…).

Step 7 : Follow-up for options counseling may be necessary depending on the situation. If
follow-up is appropriate to make sure that the information given was appropriately handled, then
proceed with proper follow up. This may include, but is not limited to, calls to family members,
a hospital, the police department or a mental health organization. If it is evident that the
individual received the appropriate assistance before the termination of the contact, then no
further follow-up is required, but adequate documentation to substantiate no further follow-up is
necessary.




                                            63
                                                        Physicians

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking physician information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a physician inquiry prior to the process described
        here. The Link-Age staff should have knowledge of both public and private resources for
        physicians.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on physicians, then Link-
        Age staff is responsible to disseminate accurate information and refer individuals to appropriate
        resources or contacts.




                                                     64
Step 3: Link-Age staff will research programs and information regarding their specific need by
using the IRIS resource management or resource information located in the training manual.
Such programs for physician referrals could include, but is not limited to:
    o American Board of Medical Specialists at www.certifieddoctor.org
    o Local hospitals, which may have hotlines for physician referrals.
    o Indiana Family Healthline at (800) 433-0746.
    o County Medical Associations
    If possible or requested, complete a three-way call with the individual, Link-Age staff and
referred agency. If the individual is a walk-in, then the Link-Age staff may attempt a call using
the speaker phone option so that all parties may communicate. It is best if the referred agency
receives information on the concern from the person. However, if the individual requests that
Link-Age supply information to the referred agency, then Link-Age staff will obtain verbal or
written consent from the individual seeking assistance (or the individual’s Power of Attorney)
and then proceed to:
        AA. Contact the referred agency for a verbal referral, OR
        BB. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
        CC. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             65
                                           Pre-Admission Screening

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        about admission to nursing facilities which requires the Pre-Admission Screening (PAS).

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a PAS inquiry prior to the process described here.
        A PAS inquiry may be made by a variety of sources, including the individual, family members,
        discharge planners or social workers. This procedure also takes into account the fact that
        individuals may or may not ask specifically about PAS, however the contact is deemed a PAS
        inquiry based on the individual’s inquiry about nursing facility placement.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves the placement of an individual in a nursing facility
        and/or a PAS is requested, then follow “in-house” procedures to route the inquiry correctly.


                                                     66
Step 3: Before any PAS work has begun, each inquiry about nursing facility admission and/or
PAS must have completed Options Counseling. Options Counseling must be completed with the
individual, individual’s family member(s) or the individual’s Power of Attorney. See the Options
Counseling SOP. If it is determined that another option would suite the individual better, then
follow the procedures for that option. However, if the individual’s option requires nursing
facility placement, then proceed with “in-house” procedures for completion of PAS.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             67
                                                 Prescription Drugs

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking prescription information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that an inquiry has been determined as a prescription drug inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for prescription drugs.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on prescription drugs, then
        Link-Age staff is responsible to disseminate accurate information and refer people to appropriate
        resources or contacts. Such prescription inquiries could include, but are not limited to:
            o Prescription Payment Assistance Programs
            o Medicare Part D

                                                     68
   o   Private Insurance Prescription Coverage
   o   Medicaid
   o   Prescription Information
   o   Pharmaceutical Assistance Programs

Step 3: Link-Age staff will research programs and information regarding their specific need by
using the IRIS resource management or resource information located in the training manual.
Such programs for prescription information and/or assistance could include, but is not limited to:
    o The Medicare website at: www.medicare.gov for Medicare and Medicaid information.
    o SHIP, State Health Insurance Assistance Program, to discuss insurance options.
    o IRIS search for Prescription Payment Assistance Programs through local agencies.
    o Local pharmacies and their programs.
    o Drug manufacturer websites.
    o Prescription information on the following website: www.talkaboutrx.org.
         If possible or requested, complete a three-way call with the individual, Link-Age staff
and referred agency, or if the individual is a walk-in place the phone on the speaker option so
that all parties can communicate. It is best if the referred agency receives information on the
concern from the individual. However, if the person requests that Link-Age supply information
to the referred agency, then Link-Age staff will obtain a verbal or written consent from the
individual seeking assistance (or the individual’s Power of Attorney) and then proceed to:
         DD. Contact the referred agency for a verbal referral, OR
         EE. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
         FF. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             69
1151 S. Michigan Street
                                             Presumptive Eligibility
South Bend, IN 46635


Control Information

                   Revision:
                   Issue Date:
                   Previous Issue Date:
                   Effective Date:

                   Approved By:_____________________________________________

                   Approval Date:____________________________________________



Purpose

         The purpose of this document is to provide instructions on how AAA staff will expedite access
         to home and community based services for individuals not currently on Medicaid.

Scope

         This procedure is applicable to all AAA sites across the state of Indiana.

Procedure

When a person has been identified as potentially eligible for an Aged and Disabled Waiver the following
applies:
   1. On Medicaid – the consumer may be given a short term (not to exceed three months) care plan
        with CHOICE as the funding source. This will allow the consumer to remain or return home as
        soon as possible while waiting for the Wavier approval process to take place.
   2. Close to Medicaid eligibility – when the Area Agency staff has determined that the individual is
        close to Medicaid eligibility, the individual may be given a short-term (not to exceed six months)
        care plan with CHOICE as the funding source. During the six months the staff is to counsel the
        individual on Medicaid eligibility and monitor their progress in meeting eligibility. Staff is to
        begin the Waiver application process as soon as the consumer reaches a Medicaid eligibility
        range.

         When the individual becomes close to Medicaid eligibility, the CM will begin the work-up of the
         Waiver. Once approved by the State, the CM will assist the individual either through Central
         Enrollment or by working with the family, to obtain Medicaid status.

         If the application process takes longer than 6 months, the CM should meet with the Home Care
         Director to determine whether or not the care plan should be extended an additional three months
         to enable the individual to access the Waiver.


                                                     70
Consumers will be required to sign a document (see attached) verifying that the income and asset
information they provide is accurate to the best of their knowledge. The document will also
outline possible penalties for misreporting or misrepresenting income information.




                                           71
                                          Private Case Management

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking private case management.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a private case management inquiry prior to the
        process described here. The Link-Age staff should have knowledge of both public and private
        resources for private case management.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on private case
        management, then Link-Age staff is responsible to disseminate accurate information and refer
        individuals to appropriate resources or contacts.




                                                     72
Step 3: Link-Age staff will refer to “in-house” procedures for making referrals for private case
management.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             73
                                                    Senior Centers

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking senior center information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a senior center inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for senior centers.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on senior centers, then
        Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts.

                                                     74
Step 3: Link-Age staff will inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. It
is best if the referred agency receives information on the concern from the individual. However,
if the caller requests that Link-Age supply information to the referred agency, then Link-Age
staff will obtain verbal or written consent from the individual seeking assistance (or the
individual’s Power of Attorney) and then proceed to:
         GG. Contact the referred agency for a verbal referral, OR
         HH. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
         II. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for senior center inquiries may be necessary depending on the situation. If
follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            75
                                                SHORT-TERM SERVICES




Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles calls
        seeking short term services or resources for the aged, physically disabled and low income. The
        service will offer a short-term intervention to achieve a desired outcome and promote long term
        independence.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. Short-term service
        of home delivered meals, adult day service, homemaker, attendant care, home health aide, skilled
        therapies and nursing may be delivered to individuals meeting certain criteria for a period not to
        exceed 6 weeks.

        These services are designed to provide a service delivery option for individuals who require
        short-term assistance through a life crisis or significant or stressful event that has compromised
        their independent living status.

        Note: This is not intended to be a stepping stone to long-term services or to take the place of
        services funded through Medicare, Medicaid, or private pay.

        Eligibility requirements:
        1. The individual must meet CHOICE eligibility guidelines, including income requirements, but
            may not be a current case managed client.
        2. The problem must be new, acute, or an exacerbation of an existing condition that is expected
            to resolve within 6 weeks or less. Chronic, on-going disabilities or medical conditions are
            not appropriate for limited services and should be referred for more appropriate long-term
            assistance.




                                                     76
      3. Recent surgery, hospitalization, nursing home discharge, or medical treatment from which
         the individual is recuperating and information indicates improvement or stabilization will
         occur within a 6-week period are examples of appropriate referrals.
      4. Loss of a primary caregiver due to a similar situation as described above that will be resolved
         within 6 weeks or less or assurance by family that a plan is in process to assume primary
         caregiver responsibilities. The primary focus here would be to provide interim assistance
         until arrangements can be made.
      5. Financial assistance is needed for short-term, health-related care when no other funding is
         available and it has been determined that total payment out of pocket would be difficult or
         insurance payment for the in-home care is questionable.
      6. The situation has deteriorated to the point that the individual’s health and/or safety are at risk.
         (APS must also be involved.)
      7. The individual has not already utilized short-term services. Rare exceptions in the presence
         of extenuating circumstances will be considered with determination made by Case
         Management Director.
      8. Homemaker services will be limited to no more than 16 hours for the six-week timeframe.

Responsibility

      Link-Age staff members who assist callers are accountable for initiating this procedure.

Supporting Documentation

      Training curriculum developed for each job description.

Procedure

Step 1: Link-Age Staff takes referral and after discussion with caller determines that the individual
would meet criteria for short-term services. All options are discussed with client/family at this time
including Medicare, Medicaid, CHOICE, private pay and nursing home placement. The 6-week time
limit is stressed.

Step 2: Link-Age Staff should complete eligibility screen on referral because the individual must be
CHOICE eligible to be considered for short-term services.

Step 3: Link-Age Staff provides referral to Case Management Director for review and assignment to the
appropriate Case Manager within one (1) business day.

Step 4: Case Manager completes a Case Management evaluation to determine appropriate short-term
services. Case Manager submits completed long-term care service application, asset worksheet,
eligibility screen with narrative, ACCM sections as appropriate, authorization to release personal
information, *Care Plan (handwritten and computer) and Outcome Summary to Case Management
Director within seven (7) business days of referral. Informal supports must be included on the Care
Plan.

Step 5: Upon approval, Case Manager will provide a copy of the Care Plan to the chosen vendor within
one (1) business day. The Case Manager will also make a note in the comment section of the
demographics screen that the client was approved for short-term services with the date and their initials.

                                                   77
Step 6: Five business days prior to the end of the Care Plan, the Case Manager will visit or call the
individual to remind them of the upcoming discharge date, assess progress, and record outcomes. A
similar follow-up call should be made to the vendor. The Case Manager will then complete a Notice of
Service Action to terminate services and send into the office. The Case Assistant will mail the Notice
of Service Action to the client and the vendor and change the CM code on the demographic section in
InSite.

Step 7: The Case Manager will recommend in the reason section of the NOSA if the individual should
be on the waiting list and/or if they should continue to receive meals after the short-term plan of care
ends.

Step 8: The Case Assistant will use the NOSA as the trigger to assure that the Case Manager section is
updated on the demographic screen of InSite.


*When finalizing a Care Plan a message pops up asking if you want client removed from the wait list.
This should be answered NO.




                                                   78
==

                                                    Social Security

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking social security information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a social security inquiry prior to the process
        described here.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on social security, then
        Link-Age staff is responsible to disseminate accurate information and refer individuals to
        appropriate resources or contacts.

        Step 3: If the inquirer seeks information about social security benefits, identity theft or any other
        basic social security question, Link-Age staff will refer to resource information in the training

                                                     79
manual and/or the www.socialsecurity.gov website to help answer any basic questions that the
inquirer might have. If the inquirer still seeks further assistance, which the Link-Age staff can’t
help with, then the Link-Age staff will inform the inquirer to contact one of the following
resources:
    o Local Social Security Office, or
    o www.socialsecurity.gov
    If possible or requested, complete a three-way call with the individual, Link-Age staff and
Social Security Office, or if the individual is a walk-in, place the call on speaker phone so that all
parties can communicate. It is best if the Social Security Office receives information on the
concern from the inquirer. However, if the person requests that Link-Age supply information to
the referred agency, then Link-Age staff will obtain verbal or written consent from the individual
seeking assistance (or the individual’s Power of Attorney) and then proceed to:
        JJ. Contact the Social Security Office for a verbal referral, OR
        KK. Send a referral to the Social Security Office by fax, e-mail, mail, etc., OR
        LL. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the person is actively working with a case manager or another department within the
agency, the active case manager and supervisor must be notified (via e-mail and/or telephone)
about the contact.

Step 6: Follow-up for inquiries may be necessary depending on the situation. If follow-up is
appropriate to make sure that the concern was resolved, Link-Age staff needs to pursue proper
follow up. This may include, but is not limited to, calls to the initial contact, family members or
the referred agency. If it is evident that the individual received the appropriate assistance before
the termination of the contact, then no further follow-up is required, but adequate documentation
to substantiate no further follow-up is necessary.




                                             80
                                                   Support Groups

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff handles inquiries
        seeking various support group information.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana. This procedure
        assumes that a contact has been determined as a support group inquiry prior to the process
        described here. The Link-Age staff should have knowledge of both public and private resources
        for support groups.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Probe the individual for accurate and descriptive information about the situation or
        concern. If the situation or concern involves resources or information on support groups, staff
        needs to identify the specific type. Such examples could be:
            o Caregiver
            o Alzheimer’s
            o AIDS

                                                     81
   o Bereavement.
      Link-Age staff is responsible to disseminate accurate information and refer individuals to
   appropriate resources or contacts.

Step 3: Link-Age staff will either take and process a referral for in-agency support group
programs, if applicable, or inform the individual to contact a resource, and, if possible or
requested, complete a three-way call with the individual, Link-Age staff and referred agency. It
is best if the referred agency receives information on the concern from the individual. However,
if the individual requests that Link-Age supply information to the referred agency, then Link-
Age staff will obtain a verbal or written consent from the individual seeking assistance (or the
individual’s Power of Attorney) and then proceed to:
         MM. Contact the referred agency for a verbal referral, OR
         NN. Send a referral to the referred agency by fax, e-mail, mail, etc., OR
         OO. Assist in completing an application, if applicable.

Step 4: After the conclusion of the contact, document all information in IRIS. All databases such
as INSITE must be referred to and, if the individual’s information is present, then the database(s)
must be updated.

Step 5: If the individual is actively working with a case manager or another department within
the agency, the active case manager and supervisor must be notified (via e-mail and/or
telephone) about the contact.

Step 6: Follow-up for support group inquiries may be necessary depending on the situation. If
follow-up is appropriate to make sure that the concern was resolved, Link-Age staff needs to
pursue proper follow up. This may include, but is not limited to, calls to the initial contact,
family members or the referred agency. If it is evident that the individual received the
appropriate assistance before the termination of the contact, then no further follow-up is
required, but adequate documentation to substantiate no further follow-up is necessary.




                                            82
                                                    Transportation

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff is to handle
        transportation inquiries.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

      Step 2: Determine, from the inquirer, the nature of the transportation need.
    o Medical Transportation (i.e. doctor, dental, eye care, etc.)
    o Errand Transportation (i.e. grocery shopping, medication pick up,
                  banking, etc.)
    o Leisure Transportation (i.e. recreational activities, leisure shopping,
                  family or friend visits, etc.)
    o Other Transportation (any other transportation need, not listed above)
      Step 3: Determine what kind of hands-on assistance, if any, is required for the individual in need
      to enter a vehicle.

                                                     83
o   No assistance needed
o   Needs a “steady” arm to assist into and out of the vehicle
o   Needs weight bearing assistance into and out of the vehicle
o   Needs wheelchair lift

  Step 4: Determine the following about the individual in need:
o Demographics (name, address and phone number)
o Age

    Step 5: Research and discuss transportation options with the inquirer, based on the information
    received. Use the IRIS database or the resource information located in the training manual to find
    applicable programs and services. Search for specific transportation programs, such as (in no
    particular order):
o   Mass Transportation options (i.e. city bus, etc.)
o   Private Company transportation options (i.e. taxi, etc.)
o   Medical transportation options (i.e. EMS, ambulance, disease-related transportation programs,
    etc.)
o   Senior Program transportation options
o   Transportation Expense Assistance Programs

  Step 6 : If the inquirer is interested in any of the programs discussed, offer additional assistance,
  such as:
o Assisting the inquirer with applying for a program, or if assistance is not needed, providing the
  appropriate paperwork to apply for a program, if that paperwork is available.
o If the paperwork to apply is not readily available, offer to contact the appropriate agency or
  person. This can be done by a three-way call, if the inquirer is a caller. If the inquirer is a walk-
  in, a call can be made using the speaker phone options so that all parties can communicate. If
  they do not desire additional assistance, provide them with the appropriate information required
  to make their own contacts.

    Step 7: Make sure that all available transportation options have been exhausted. Confirm with the
    inquirer that there is no other need or option to be discussed.

    Step 8: After the conclusion of the contact, document all information in IRIS. All databases (such
    as INSITE) must be referred to and, if the individual’s (the person in need) information is
    present, then the database(s) must be updated.

    Step 9: If the individual is actively working with a case manager or another department within
    the agency, the active case manager and supervisor must be notified about the action taken (i.e.
    referred them to a transportation agency, signed them up for a transportation program, etc.).

    Step 10: Follow-up may be necessary depending on the situation. If follow-up is appropriate to
    make sure that the information given was appropriately handled, then proceed with proper
    follow-up. This may include, but is not limited to, calls to family members, the individual
    seeking assistance or the referred agency. If it is evident that the individual received the
    appropriate assistance before the termination of the contact, then no further follow-up is
    required, but adequate documentation to substantiate no further follow-up is necessary.


                                                 84
                                       Veterans’ Benefits Home Care

Control Information

                Revision:
                Issue Date:
                Previous Issue Date:
                Effective Date:

                Approved By:_____________________________________________

                Approval Date:____________________________________________



Purpose

        The purpose of this document is to provide instructions on how Link-Age staff will offer home
        care benefits information to wartime veterans and their spouses.

Scope

        This procedure is applicable to all Link-Age sites across the state of Indiana.

Responsibility

        All Link-Age staff who assists any inquirer (whether by phone, fax, e-mail or walk-in) is
        accountable for implementing this procedure.

Supporting Documentation

        Training curriculum developed for each job description.

Procedure

        Step 1: All calls will be directed to the Link-Age staff.

        Step 2: Determine, from the individual, the nature of the need.

      Step 3: In order to be eligible for extra money to pay for non-skilled home care the veteran
      and/or their spouse must meet the following requirements to be eligible for this funding:
    o The Veteran must be a wartime veteran. This means the veteran must have had at least one day
      of active duty during wartime to be considered a wartime veteran.
                           WWII: 12/7/1941 – 12/31/1946
                           Korean War: 6/27/1950 – 1/31/1955
                           Vietnam War: 8/5/1064 – 5/7/1975 (in country 2/28/1961)

                                                     85
                      Gulf War: 8/2/1990 - Present
o   The Veteran must have been honorably discharged from the service.
o   The Veteran must be at least 10% disabled, or totally disabled, or over the age of 65.
o   The Veteran must be on social security (longevity, disability, or SSI).
o   The Veteran must have limited income
                      Income limits change each year. Verify with local Veteran’s
                         Representative.
o   The Veteran must have a disability that is not connected to his/her military service, such as CHF,
    Alzheimer’s, COPD, etc., which necessitates the need for non-skilled care help, such as attendant
    care and/or homemaker help.

    Step 4: How to apply: The Veteran or widow must complete a VA Form 21-526, parts A, B, and
    C along with all the requested forms/needed attachments. If the Veteran is elderly (over age 65),
    homeless, or a minority, their application will be expedited. It can take up to 6 months for this
    application to be processed/approved.

    Step 5: If the Veteran requests to speak with a VA representative, a 3-way call will be attempted
    to expedite communication. (A list of VA representatives for the state of Indiana is attached.)

    Step 6: Document all information in IRis.




                                                86
                                                  Waiting List Management

Control Information

                  Revision:                            001A
                  Issue Date:
                  Previous Issue Date:
                  Effective Date:

                  Approved By:_____________________________________________

                  Approval Date:____________________________________________



Scope
Indiana Area Agencies on Aging is designed to provide community based services to the Aged and
Disabled. With a growing increase for in-home community based support services and limited funding,
all AAA’s will be required to develop a waiting list to maintain client information until funding becomes
available. The following operating procedure will apply for all Indiana Area Agency on Aging to ensure
a continuum of service for those waiting to be targeted.

Procedure

All AAA will comply with the following intake process before placing a consumer on a waiting list for
community home-base services;

         1. Provide demographic information
         2. Pre-determined, functional and financially eligible, by completing an E-Screen, Asset
            worksheet, and CMAG over the phone.
         3. Return a signed long term service application

Initial determination of eligibility will be done over the phone and must be completed within 72 hours of initial client contact.

    A. Non-eligible consumers receive;
          a. Letter of non-eligibility
          b. Copy of the appeal process
          c. Referral to other services

    B. Eligible consumers receive;
           a. Letter of eligibility
           b. Long-term service application
           c. Statement including funding eligibility
           d. Explanation of waiting list procedures


                                                               87
           e. Date consumer will be placed on waiting list.
           f. 30 days to confirm eligibility by returning long term application

The following operating procedures will ensure clients who are placed on a the waiting list are continued
eligible by maintaining up to date accurate data until targeted for in-home services.

   A. all waiting list client information will be updated yearly

           a. Update eligibility screen

           b. Obtain Long-term application

   B. Unable to contact client to update information

           a. Utilize Social Security Death Index
           b. Local Newspapers

           c. Send letter – no response in 30 day client is removed from waiting list.


Responsibility

Local Area Agency on Aging will be responsible for maintaining accurate and up to date functional and
financial information on all consumers on a waiting list seeking in-home support services under the
CHOICE, SSBG and Title III programs.

Indiana Division on Aging will be required to maintain waiting list for A&D, TBI, AL and MFC
Medicaid Waivers.

Supporting Documentation

Eligibility Screen in Insite
Asset Worksheet
Standardized Letter for eligible and non-eligible clients
Long-term service application
Appeal process



♦ See Logic Model for visual procedure




                                                    88

				
DOCUMENT INFO
Description: Indiana Nursing Home Neglect Attorney document sample