You Have The Right To Learn If You Can Live In The Community And Get The Services And Support You Need.
If you or someone you know is in a nursing home or about to go into a nursing home, nursing home staff must now ask you if you want to talk to someone about the possibility of returning to the community (your home, an apartment or another appropriate setting) and get the care you need there.
The nursing home staff must ask this question whether they believe you are able to be discharged and receive care in the community. They must ask this question regularly, since your needs and the services available in the community may change over time.
If you say yes to this question, you must be referred by the nursing home staff to a local organization (Local Contact Agency) who will visit you to understand what services and support you need and they, with you, will look into the possibility of you receiving care in the community.
If you say “yes” to the question, it doesn’t mean you have to leave the nursing home nor does it guarantee that you will move back to the community right away. Saying “yes” simply starts the conversation about your options with an outside agency.
See, “Your Right to Get Information about Returning to the Community” http://www.medicare.gov/pubs/pdf/11477.pdf
Making Sure Your Interests are Understood
In order to identify all people staying in nursing homes who want to talk to someone about moving back into the community, the nursing home assessment form (Minimum Data Set – MDS) was changed. The section on “Participation in Assessment and Goal Setting (Section Q)” was rewritten to focus on your wishes, provide you with the opportunity to discuss your expectations for care, and engage you in discharge planning.
Nursing home staff must now ask you (or a family member, or significant other, if you are unable to understand or respond) directly whether you want to go back to living in the community. They must also ask whether you want to talk to someone about community care options and supports. If you say yes, the facility must refer you to a local contact agency (LCA).
You must be asked this question when you are admitted to the facility and then quarterly, on an annual assessment, and at any significant change in your condition. If you decide that you do not want to be asked that often, tell your social worker (your refusal must be documented).
Once you are referred to a local contact agency, you will be visited by a representative of that agency who will discuss the various options with you. If the options given to you are ones you want and are eligible for, the nursing home discharge planner or social worker is responsible for helping you reach your goal of moving back to the community. They must then work with you to carry out any discharge plans. The Local Contact Agency representative and the social worker/discharge planner may also continue to help you.
Make Sure You Are Asked This Question and Are Referred If You Say Yes
If you (or a resident you know) is not being asked this question or are not being referred if you said yes, ask your social worker why. If you do not get an answer you can agree with, contact your ombudsman. If, your social worker/discharge planner does not seem to be working on your discharge plan after you have followed up, contact your ombudsman. Every nursing home has a sign posted with the ombudsman telephone number.
HOW WELL IS THIS WORKING?
CIDNY was awarded a grant from the New York Community Trust to evaluate how well this system is working for people who have developmentally disabilities. Our report has been published and can be found at the links at the top of this page. The goals of the project were to:
- Improve outcomes for nursing home residents with developmental disabilities (and their family members) who want to receive care and live in a less restrictive setting;
- evaluate the New York State process for complying with Section Q;
- make recommendations for the application of Section Q to people with developmental disabilities; and
- develop training for local organizations on how to help their clients with developmental disabilities (and families) better understand Section Q and the referral process in order to improve their chances of receiving care in a more integrated setting.
CIDNY gathered information from:
- Nursing home social workers/discharge planners in New York City through surveys and interviews;
- Local Contact Agency representatives through surveys and interviews;
- New York State officials;
- New York State and City ombudsmen;
- other states through interviews with consumers, government representatives, ombudsmen, and providers and researching written materials; and consumers.
We have put together links to some resources that may be helpful. While the links are placed for the audiences the resources are directed to, you may want to browse all the links to get a sense of the role each type of staff may play.
For Families and Consumers:
For Ombuds Staff:
For Nursing Home Staff: