HCBS Final Rule - Person-Centered Planning: Lessons From the Field Webinar Transcript

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[Mark] Good morning. This is Mark Kissinger. I´m coming to you from the Health Department. This webinar is about the Home and Community–Based Services Person–Centered Planning Lessons from the Field. Here with me in the room is…

[Jennifer] Jennifer Miller, Administrator of an Adult Care Facility, Valley Residential Services, located in Herkimer County.

[Josephine] Josephine Tramontana, Program Director of Sunrise Adult Day Health Care Center in Brooklyn, NY.

[Ann] Ann Selfridge, Executive Director of the ACT Care Group, a social adult day program in Staten Island, NY.

[Madeline] Madeline Kennedy, I work on HCBS Final Rule implementation at the Department of Health.

[Madeline] When it comes to the Home and Community–Based Services Final Rule standards, we´re going to review the standards for all settings, The Final Rule states that all settings where HCBS are provided and where people receiving HCBS live must be integrated in and support full access to the greater community and be selected from among options by the individual. HCBS settings must also ensure an individual´s right to privacy, dignity and respect, and a freedom from coercion and restraint, optimize autonomy and independence in making life choices, and facilitate choice about services and who provides them.

The HCBS rule also included person–centered planning requirements such as a person–centered service plan for every person who receives Medicaid funded HCBS and a significantly enhanced version of that person–centered planning, most of the conditions of which are required as of the rule´s March 2014 effective date. We know that the person–centered planning requirements are included in Section 2402A of the Affordable Care Act.

The Person–centered planning process must also be driven by the individual who is served, include people chosen by that individual, provide necessary information and support to the individual to ensure that they direct the planning process as much as possible, and is timely and occurs at times and locations of convenience to the individual.

Please note that when we refer to the individual we also are referring to their representative if they have one.

In regard to person–centered planning concepts, there are three key concepts to understand which underpin New York´s efforts to move closer to HCBS Final Rule person–centered planning standards. First we have person–centered thinking, which is a way of thinking that helps create the means and resources for a person to live a life that they value. Person–centered planning is a way to assist people needing HCBS services and supports to construct and describe what they want and need to bring purpose and meaning to their life. Person–centered practice is the alignment of service resources and supports that give people access to the full benefits of community living and ensure they receive services in a way that helps them achieve individual goals. Person–centered thinking is more than a set of words or a checklist to follow, it´s a paradigm shift, moving away from previously established ways of thinking, approaches, and a way of doing things to a new perspective, a new set of competencies, and a new approach.

When it comes to person–centered thinking there are some commonly held myths such as "we are already doing it." What person–centered thinking is not: simply asking a person what they want thinking that a well–developed plan leads to a –good life (as we know that it often takes more than a well–developed plan to do that); nor are person–centered activities are only appropriate for one type of disability; or that only staff working directly with the individuals receiving services and supports need to be engaged in person–centered activities; or that person–centered thinking and practice can be done without significant organizational change.

For more detail on the person–centered planning requirements in the HCBS Final Rule, we know that person–centered plans must: assist the person in achieving outcomes that they define for themselves in the most integrated community setting that they desire; ensure delivery of services in a manner that reflects personal preferences and choices; help promote the health and welfare of those receiving services; and take into consideration the culture and the languages of the persons served. Person–centered plans must also use plain language, include strategies for solving disagreements, offer choices regarding the services and supports the person receives and from whom, provide methods to request updates, and indicate what entity or individual will monitor the primary (or the main) person–centered plan. Person–centered plans must also identify individuals´ strengths, preferences, needs (both clinical and support needs), and their desired outcomes.

The Final Rule also talks about allowable modifications to person–centered plans, and that is in regard to settings where the HCBS provider owns the individual´s residential service, as we know there are times when supporting that individual may require modifications of the additional standards of the HCBS rule which is allowed, as opposed to blanket rules and restrictions being made to entire program, which are not allowed.

The additional standards for all settings are having the freedom and support to control one´s own schedule and activities, and access to food and visitors at any time. And the additional standards for residential settings are that individuals in residential units will have a legally enforceable agreement giving them the same protections and responsibilities as any tenant living in that jurisdiction, privacy in sleeping or living units, units have lockable entrance doors with the individual served and appropriate staff having keys or key codes to those doors, a choice of roommate in shared units, and freedom to furnish and decorate sleeping or living units.

Modifications to any of the additional standards on the previous slide cannot be made on an entire setting. They must be made on a case–by–case basis and be supported by a specific assessed need and justified in the person–centered service plan. All states have until March 2022 to comply with making the modifications to the additional standards within person– centered plans.

The modifications to the additional standards that we just reviewed must be documented in the person–centered plan and include a specific and individualized need, (which means that a diagnosis alone does not allow you to make the modification, it has to be based on a specific need that the person has), positive interventions and supports used prior to any modifications, less intrusive methods of meeting the need that were tried and did not work, and a clear description of the condition that is directly proportionate to the specified need. We must also include in the person–centered plan regular collection and review of data measuring the ongoing effectiveness of the interventions used, established time limits for periodic review to determine if the modification is still necessary, informed consent of the individuals supported, (or their representatives should they have one), and assurances that the intervention and supports will cause no harm to that individual.

We have here a case example of a modification. In this example, Judy struggles to manage her scheduled activities at the adult day health care where she receives services. She tends to isolate due to symptoms related to her dementia and depression. With Judy´s or her representative´s informed consent staff can work with Judy and her care or case manager to develop a six–month plan to support her with scheduling and participating more fully in activities. Judy, her staff, and her case manager will ensure that this is documented properly and her person– centered plan will be updated within six months to see if she still needs support with this. The key here is that we´re following up and we´re not making an assumption that she cannot at some point manage the ability to control her own schedule. What do quality person–centered plans mean? People have control over the lives they have chosen for themselves, people are recognized and valued for their contributions; past, current, and importantly, potential contributions to their communities, people live the lives that they want versus having services that may be chosen for them, may they may avoid duplication of services and reduce costs of unwanted services – if done correctly.

Alright. Now we´re going to move on to one of our provider presenters from Valley Residential Services, Jennifer Miller.

[Jennifer] Good morning. I would like to start off just talking a little bit about our facility. Valley Residential Services has been open since about 2015. We are located in Herkimer County. We are a rural setting approximately 75 miles from Albany as you can see on the map. It´s a 48–bed adult care facility which offers an Adirondack lodge themed ambience. We have 36 assisted living program beds and 12 enriched housing program beds. Our payer mix is 75% Medicaid and 25% private pay. There´s a total of 46 apartments that encourage independent senior living with privacy. We have 44 single occupancy apartments that are about 378 square feet. They do have a kitchenette, living room, bedroom, and private bathroom. We do have two double occupancy apartments, approximately 452 square feet, that offer a kitchenette, living room, bedroom, and private bathroom. We are currently under construction and expanding an additional 14 enriched housing units. All of these units are large enough to accommodate couples. Construction actually is complete, and we are admitting to those new rooms. Here are a couple samples of our floor plans just to show you what our apartments look like, a very private setting for the individual that lives there, in the single and the double units.

Individual autonomy and choice: Residents drive their own schedules and make decisions based on their individual circumstances. The residents often change or modify their daily activities. Residents and families are included in the development of the care plan and individualized service plans. Plans are based on personal preference as well as assessed needs to promote the health and welfare of the individual.

Residents and their families are invited to attend care planning meetings to discuss and request additional or different services. We do typically meet every six months to do that.

Privacy and visitor policy: Residents have keys to their apartments and are free to lock the door if they wish. We have several common areas throughout the facility that are available for visitation space outside of the resident´s apartment. The facility is open to visitors 24 hours a day, seven days a week. Facility doors are locked for safety at 9 PM daily. Afterhours access is obtained via doorbell.

Some examples… All residents are issued a wrist coil with keyring upon admission with their apartment key, mailbox key, and bathroom lock drawer key. All residents are encouraged to wear their keys on their wrist. If the resident is having difficulty managing their keys we will add an intervention to his or her care plan to have the home health aides assist on each shift, i.e. a special place for them to keep them or routine for where to put them when they´re not in use. We also audit all resident keys as part of our quality improvement program on a quarterly basis to make sure that all the residents do still have those.

Our dining experience: Three meals a day are served in our community foundation dining room whose focal point is a stone hearth and fireplace. We do have restaurant style seating and dining room hours which allow the residents the freedom to attend meals at their leisure.

Access to food outside of scheduled meal times: We do have an Adirondack Bank Café that is located in our social area which you can see in the picture here. It is open to the residents and their guests and offers coffee, tea, water, juice, baked goods, and fresh fruit. That is available daily from 8 AM until 8 PM. Each unit or apartment is also equipped with a kitchenette that has a full–size refrigerator, freezer, and microwave.

Some examples of that… All of the main meals are offered daily. We also have four to five alternates that we offer, just to give a little bit of choice for meal preference. We encourage residents to keep food and snacks in their apartments. We do up to three shopping outings a month, they´re scheduled as part of our activities calendar, giving the residents opportunity to purchase items in various local stores. The supervisor of the building does have access to the facility kitchen to prepare a light meal on off hours.

Next, activities: We do have activities that are held daily with a full activities calendar at 10 AM, 2 PM, and 6 PM. We have outings, go to the movies, games, educational programs, and music programs. Monthly calendar planning meetings are held to discuss resident suggestions and preferences for programs and scheduled outings for the next month, so they do have a lot of input into what activities are going on in the building. One–on–one activities are scheduled for residents who do not wish to participate in group activities. We do have some residents who prefer one–on–one cooking experiences, reminiscing and shopping. Outings for residents that wish to go out solo are scheduled upon request as staff and transportation permit.

Transportation: Herkimer County is very rural. Public transit is not available to and from our facility. We do provide transportation to medical appointments within a ten–mile radius from the facility at no charge to the resident. Transportation to medical appointments outside of a ten–mile radius are subject to a charge. Transportation for non–medical related purposes will be provided at the discretion of administration, and charges may be applied for transportation for non–medical related purposes. Transportation is provided to all outside activities and/or programs scheduled by the facility at no additional charge.

[Madeline] Thank you. Now we have Josephine Tremontana from Sunrise Adult Day Health Care Center.

[Josephine] Good morning everyone and thank you for having me here on this webinar. Person–centered planning at Sunrise Adult Day Health Care Center. Sunrise Adult Day Health Care Center opened in 1996. It´s part of the Four Seasons Nursing and Rehabilitation Health Care System located in the Canarsie section of Brooklyn. Our integrated health care system offers a continuum of care that includes skilled nursing and rehabilitation services, two medical model adult day care programs, social model program, dialysis center, a LCHSA and a CHHA, and our on–site pharmacy service.

Who do adult day care programs service, and what do we provide? Registrants must be functionally impaired and must need and receive medical interventions to treat a chronic health condition. Most registrants have multiple diagnoses including a secondary mental health diagnosis. Some of the top diagnoses that we see at the adult day health care center are diabetes, COPD, and hypertension. Secondary diagnoses are schizoaffective disorders, depression, and bipolar disorder. In accordance with a referral by the primary care physician or managed long–term care plan, and in conjunction with a comprehensive interdisciplinary assessment, social and health care needs can be met by the deliverance of adult day care services.

ADHD minimum core services: In accordance with our regulatory requirements, some of the core services we offer at Sunrise Adult Day Care Center are skilled nursing care, personal care, physical, occupational, and speech therapy, nutritional services, pharmacy review, case management, health education seminars, care planning, social services, therapeutic and recreational activities, and referrals for specialty care and transportation.

Regulatory requirements for adult day–care care planning: Adult day–care person-centered care plans are developed based on the comprehensive and interdisciplinary assessments, the UAS of New York, within five days of the admission to the adult day care program or within 30 days following admission. The UAS also captures needs and preferences. The care plan is a crucial part of the medical record and must be updated every six months and whenever there is a change in condition.

Every care plan must include the diagnosis, the mental status, the type of equipment and the services required, frequencies of visits, prognosis, rehabilitation potential, functional limitations, planned activities, nutritional requirements, medication and treatment, measures to protect against injury, and orders for therapy. Every care plan must include medical, nursing, social, nutritional, rehabilitation, therapy, activity, goals that reflect the needs, the strengths, the limitations, and the personal preference of our registrants.

How do adult day care programs meet regulations and develop person–centered plans? At Sunrise Adult Day Care, we strive to develop care plans that are person–centered. Care plans must be interdisciplinary. Each discipline participates in the developmental goals and the interventions and work with the client to identify strength, preferences, and person–centered goals. The adult day health care program develops care plans based on the client´s feedback or input. For example, registering council meetings, activity questionnaires, comprehensive assessment and staff observation.

Our registrants, caregivers, and representatives are invited to attend care plan meetings in person or may participate in a conference call in accordance with their schedule needs and desires. Care plan meetings happen at a time that´s convenient for our registrants.

Sample person–centered adult day care services care plan:

Sunrise Adult Day Care participates in several community integrated–programs such as the Kings County Hospital and Commodity Supplemental Food Program and Bedside Campaign Against Hunger for a food pantry on site. This benefits both, our Canarsie registrants and the adult day care registrants who experience food insecurities. Meals are prepared for our registrants that are unable to cook at home and sent home with them. This is based on an assessed need. Adult day care programs in Brooklyn also experience increased numbers of participants residing in shelters. Social workers help those clients apply for housing and refer to other community–based agencies.
Our nursing department works closely with our registrants to help maintain them in the community by pre– pouring medications, delivering it to the registrant´s home if they´re unable to come to a program on a certain day, and assisting them and their family to enable them to live in the community as needed, even on days when they don´t attend. Activity professionals develop therapeutic recreational programs that benefit the participant in the home, their life, and in the community. Our menus are created based on the cultural needs and preferences of our clients. Activities are sensitive to the cultures and the spiritual needs of our registrants. Therapeutic activities play a large role in controlling and managing some of the behaviors of our registrants.

Changing the culture of care planning in adult day care: At Sunrise, we work really hard to move towards person–centered care planning, getting staff onboard for a system wide approach to person–centered care planning, learning from the changes that have happened in the nursing home, identifying our clients´ lifelong routine and care plans and the methods to facilitate continuation in adult day care. Incorporating and capturing the individual´s strength, preferences, goals, while remaining focused on their medical needs and validating their attendance in a medical model adult day care program. Moving away from RIGHT NOW terminology, no longer using nursing acronyms or terminology, and remembering each discipline must be able to understand the care plan. Keeping documentation consistent, writing what you´re doing.

Focusing on person–centered planning is not about doing more, just different. Finding mechanisms for incorporating space for individuals´ preferences and strengths or components not addressed on an electronic medical record is pertinent to the adult day care program. Ensuring that there is adequate diagnoses and interventions from the physician orders for treatment, UAS, care plan and documentation. Developing policies and procedures to address meeting person–centered preferences that conflict with professional assessments and judgments and including processes for documentation to capture all the pertinent intervention.

We develop a care plan that focuses on what the individual´s problem is, what their needs are, what their strengths are, and what their preferences are. This is a sample care plan which basically focuses on the diagnosis. The registrant has a diagnosis of insulin dependent diabetes. The registrant requires left below knee amputation due to effects of uncontrolled diabetes. His strength is that he currently states that he is willing and motivated to comply with his medications and treatment plan and sees his endocrinologist regularly. His preferences are that the registrant prefers to have his blood glucose finger sticks monitored at the adult day care program, having his adult day care nurse administer insulin in the morning and prior to lunch to ensure proper diabetes control.

The goal of the individual would be that he would want to comply with blood glucose, finger sticks, insulin administration every visit prior to lunch at the adult day care. The registrant's plan includes a no concentrated sweets diet, medications per doctor´s orders, that the registrant reports signs and symptoms of hypo– or hyperglycemia right away (examples are sweating, headaches, increased thirst, urination, increased hunger and shakiness). The registrant would verbalize understanding of the effects of elevated blood sugar levels on the body organs. The registrant would participate in physical therapy every visit and an exercise program every visit to promote better blood glucose levels.

Then the staffing interventions would be that the staff would monitor the blood glucose finger sticks every visit in the morning and prior to lunch, the staff would administer insulin per doctor´s order, and staff would provide a no concentrated sweet diet, educate the registrant regarding low carbohydrate diet, high protein diet, staff would assist with medication compliance in the home, and staff would observe for, and instruct to report any signs and symptoms of hypo– or hyperglycemia to the nurse. And the staff would work on educating the registrant regarding the effects of high blood sugar on the body organs and healing process, and the staff would work with physical therapy and exercise.

Person–centered experiences: Clients have the option to use their own transportation provided by a caregiver, a managed long–term care Accessi–Ride, or a Sunrise contract vendor. So basically, when a registrant comes to Sunrise Adult Day Care they have choice. They can choose how they get to our program, what vendor they want to use to come to our program. The registrants are assigned a team that works closely with them. On that team they have a certified nurse´s aide, a social worker, a nurse, and a recreation leader. Other staff are assigned at admission such as dietician, but they also have the choice of selecting who they want to work with. We develop activity calendars based on registrant counsel recommendations and we also have several recreational activities to meet the diverse population that we work with at Sunrise. We have a very diverse population. We have Russian, we have Haitian and Caribbean, so we try to create different types of programs that meet the cultural needs but also the spiritual needs of those individuals. Menus are developed by the registrant counsel and the nutritionist. Our registrants are able to choose between three or more food options at lunch, so we give them choice. When they arrive, they are provided with various choices, and if there´s something that they don´t see on the menu that they would like we try to accommodate as best as possible.

Our registrants can choose where and with whom they want to sit. We have three dining rooms at Sunrise, so they can choose which dining room they would like to eat their meals at. Our registrants can also choose to stay the five regulatory required hours, or they can have an extended day at the program at no additional charge.

Therapeutic activities, small and large groups: Activity calendars are developed in accordance with the preferences, the interests, strengths, and limitations of the individual. Clients always have a choice. We have many activities going on at any given time. We have physical games to promote focus on fine and gross motor skills, constructive release of energy, anger and anxiety, strengthening of lower and upper extremity activities, cognitive activities to promote stimulation, heightened awareness with a non–frustrating environment. We have creative activities to provide opportunities for emotional ventilation, creative expression, and increase of self–esteem. Communication programs that are conducted for promoting interaction, use of language, and improving word finding skills. Registrants really have an input of what activities they would like to participate in and if they just want to be an active observer they can do that as well.

Final thoughts: We are constantly striving for improving, to obtain and maintain standards of excellence, still learning and coaching staff for a more person–centered approach to deliver care, learning from our nursing home and the OPWDD system. We´re working on ‘don´t forget to document all the person– centered care management that we´re doing´. Person–centered care planning is the right thing to do. I think that we´ve always been person–centered, but we´ve used other words to name it. We focus on our registrants´ preferences, and… that´s pretty much it. Thank you.

[Madeline] Thank you. Now we have Ann Selfridge from ACT, Adults Communicating Together, a social adult day program.

[Ann] Good morning everybody. ACT is a social day program for people with Alzheimer´s, dementia, and cognitive impairments. Adults Communicating Together, ACT, is a comprehensive educational and social program that focuses on strengthening, stimulating, and retraining the brain of people diagnosed with Alzheimer´s and dementia. Our mission is to keep people with Alzheimer´s and dementia involved in carefully planned activities that have been shown to significantly improve cognitive and physical health. ACT care professionals are trained to provide the best assistance for helping people stay independent, maintain their health and hygiene, and remain involved in activities of daily living.

What we do: The ACT care group offers specifically tailored programs for people with Alzheimer´s and dementia. The goals of ACT are to focus on the goal of increasing health and brain function, decreasing negative behavioral symptoms, maximizing independence, and providing opportunities for a meaningful quality of life. For people with Alzheimer´s and dementia, social isolation is a prominent cause of anxiety, stress, paranoia and depression. When people feel any of these emotions the impact can be very debilitating to health.

When people reach a certain age, it becomes increasingly difficult for them to be active members of society. Being involved with community and taking part in daily routines that give people chances for interaction with each other is a component of living that most people are conditioned to for the majority of their lives. When time slows down as people age, many times they don´t have as frequent an opportunity to engage in socialization even at the basic level such as walking to the store, going to the bank, going grocery shopping, or enjoying leisure activities.

Why is there a need for ACT? Social day programs such as ACT present an excellent option for families, both the participant and the caretakers. Caretakers spend the majority of their time ensuring the health and safety of their loved one and are thankful to have an opportunity where their family members are welcomed and stimulated. At ACT we provide people who need extra assistance the opportunity to participate in a schedule of activities that promote wellness, build self–confidence, and promote independence and safety at the highest possible levels. People come to ACT to have a place where they can express themselves, have a good time, make friends, and be guided in positive programming that helps people feel they are involved in something meaningful that gives their day a purpose.

Benefits the participants receive: We provide full supervision, nutrition, we have a dietitian that regulates the menu based upon the standards from New York State Office of the Aging (NYSOFA), educational programming, better performance in activities of daily living (ADL) skills, diabetic monitoring, swallowing monitoring, improved body movement functions, and toileting assistance. We strive to reduce hospitalizations, we promote activities that help decrease the use of psych medications, provide family coordination with proper specialists and/or physicians as needed, and refer to community resources.´

We also provide a lot of opportunities for caregivers who spend much of their time giving assistance to their loved ones. We provide one–to–one counseling, support group services, guided meditation classes, educational opportunities, referrals to respite grant opportunities, facilitated enrollment for Medicaid free of charge, education about pooled income trusts, assistance with SNAP nutritional programs free of charge, support from social workers, and referrals to Columbia University Medical Center along with New York University´s alzheimer´s program.

The responsibilities of ACT care staff: we are trained to prepare and lead activities for participants that are designed to maintain cognitive, mental, social, and physical wellbeing. We direct programs in music and art therapy, cognitive enhancement, physical exercise, strength building, recreational parties, special events, trips in the community, and other meaningful activities. ACT maintains a flexible schedule so that we accommodate our members and value their choices. Very often the members tell us what they want out of their time at ACT, and we strive to give the group a meaningful experience. We must possess the ability to seek out new methods and principles and be willing to incorporate them into our existing practices.

Staff must be able to and provide covered services according to the participant´s care plan, respond appropriately to participant needs, and report changes in the participant´s condition to the supervising program director.

ACT Care: When people are in a position where they are placed in a nursing home, individuals react to their loss of independence with denial, anger, bargaining, depression, and acceptance. Behavior exhibited by participants in response to institutionalization includes crying, sadness, lack of cooperation, confusion, aggressiveness, which can include hitting, biting, etc.

What can we do? Education for families is very important. Most people don´t know that there are resources that exist for them in their community. At ACT, the families start their educational journey immediately after they contact one of our staff. The family will be educated about the benefits of ACT and they will be given referral information to assisting providers that will help make caregiving easier. We keep families integrated and, in a position, to utilize these resources. We provide full follow–up and we provide a flexible environment that offers lots of choices.

Families will be connected with facilitated insurance enrollers, the option to enroll in SNAP nutrition programs, referrals when appropriate to other community organizations for social work assistance, support group programs, informational seminars to physicians and in–home mental health counselors. Families will be offered meditation classes that give them a place so that they can learn stress management techniques.

The goal of the ACT team is to present the families with resources that will give a support system for keeping their loved ones who are aging at home. In regard to person–centered care, for most people the option to continue living at home is something that they value to be the most important. With the help of the families we get to know the participants as individuals, their strengths, weaknesses, and presenting concerns. For a participant, when someone joins the ACT program the staff will be able to communicate kindness, consideration, empathy, and allow the participant to express their feelings.

We inquire about a participant´s interests and their likes. We observe and take note of their dislikes. We listen to their fears, concerns and opinions. We use gentle touch and share friendly smiles. We are reassuring, and we give positive reinforcement regarding all aspects of their day.

The ACT team offers friendship and support. At ACT, we offer choices. We like to know what they enjoy eating. We know their allergies and we know their favorite foods. We know exactly how a person enjoys their coffee. At ACT, we offer the group their favorite fruit, and we offer a variety so that people have options.

Participants make their own decisions. We ask frequently what they enjoy and what they don´t. Creative activities are planned that draw the participants interests and are catered to who is present at the program. We observe which people like to sit next to each other, who has the best conversations with each other, and who they feel the most comfortable being around. When we notice if people don´t have a good connection, and if someone annoys another person, we respect this, and we make sure that no member of the group is uncomfortable. The group and the staff have a monthly ACT council meeting where we review the last month´s activities and we discuss what we like the best and what we would like to see improve.

We also discuss new ideas for program development and what we want to see happen for the group. For example, when an ACT member brought up contacting a theater company to arrange a live performance, the ACT team was successfully able to create a partnership with a local organization who received funding through the New York City Department of Cultural Affairs. A 15–person acting troop came to ACT complete with sound equipment, props, and after the performance hosted a full Q&A.

We value nutrition and we have strict dietary policies at ACT. The ACT menu is developed by a New York State registered dietitian. We have participants and caregivers provide feedback on menu items. Nutrition services support healthy living, combat chronic disease, and provide sensory stimulation. Eating and feeding interventions can help participants remain as independent as possible.

Staff is trained about the importance of good nutrition. There is a short resting period after each meal. We combine food items with activities like cultural and educational programming. ACT staff are knowledgeable on who has certain dietary restrictions, who might be diabetic and doesn´t eat any sugar. We notice their swallowing capabilities, if they need thickening of their liquids or thin liquid drinks for the participants, what their food preferences are, and we do our best to accommodate each person.

Exercise is a big daily component of the ACT program. We do daily movement exercises. Exercise and movement are important for the aging population. If movement and exercise stop the rest of the organ systems are likely to decline and a person can develop pneumonia, infections, bed sores, or other life–threatening illness. We dance, play catch with a pillow basketball, and motivate people to sing and move.

We often sing with exercise, and just recently we partnered with the local YMCA who has a certified trainer come do exercise, low impact resistance strength building, on a weekly basis, and they are in eight–week intervals. We are on our second eight–week interval and are noting increased strength and improvement in ADL skills [in participants]. We keep in touch with family and physicians to properly communicate and carry out the best plan of care.

We have birthday parties for participants. We make each person feel special. We celebrate together like a family. We go on store trips and community outings. We have a choir and extracurricular activities. One of the ACT staff joined the Richmond Choral Society with one of our members and performed at Carnegie Hall at the end of their choir tenure. One of the ACT members was a former professional opera singer. We have spa days and activities that join enrichment for the caregiver and the caretaker.

Community partnerships are very valued and a very important part of ACT. It´s a great way to connect families to important resources, and community partnerships can help benefit the ACT members. Along with the acting troop that had come to ACT we´ve partnered with numerous community organizations that we connect with to offer a variety of interesting, informational, educational, and entertaining programs for our members.

Local businesses exchange the following services with the ACT participants: meditation for caregivers and for our ACT members, so we have a separate caregiver program and then for the actual participants as well. We have yoga programs, nutritional cooking seminars that are hosted by City Harvest, theater companies, dance studios, we´ve taken our members to trips that include Cyclone Stadium, Staten Island Yankee Stadium, Coney Island, Atlantic City Resort Casino, Shakespeare in Central Park, restaurant outings, the aquarium, the zoo, and city island restaurants. Also, we´ve gone to Broadway.

We have local entertainers that provide singing and performances, local nail salons to provide manicure and pedicure services, local hair salons to provide hair care, and organizations that have community service initiatives that want to be involved with the aging community. Often students will come in and work with our group. We have holiday parties and events at ACT where the family members are included so that there is a place where people are comfortable and can enjoy some time out of their home celebrating fun together. We have links with local occupational therapy programs to share information and techniques that are good practice for the aging population.

Final thoughts: Aging professionals spend a lot of time working to give our members the best possible care. As a team, we work very hard for our aging population, and as people get older their priorities and needs change. Together we have the ability to positively improve the aging experience and give people a chance to receive quality care. Thank you for your time.

[Mark] Thank you. We´re now going to go into needs, barriers, and next steps, then we´ll go into Q&A. So please type your questions into the chat box.

So, what is needed to meet the rule? What´s needed to meet the rule is time, time for staff supports to learn what is important to the person, listen to what is important for the person, and time to support the person in having control over the process and content of their plan as much as possible. The skills that allow for strength–based assessment, development, writing, and implementation of the plan, systems and policies that support development and implementation, and the skills, abilities, and freedom to support the individuals served with exploring what they would like to work on.

Some of the barriers to meeting the federal rule are that compliance, planning, and implementation of plans depends on deep understanding of, and ongoing commitment to, the individual being supported. Other barriers are current practice, process and flow often do not represent person–centered–thinking. Some are trying to fit person–centered thinking into existing traditional service focused systems and expecting different outcomes.

Next step towards compliance: New York State Department of Health is sponsoring a comprehensive statewide training initiative beginning this year to provide education and information regarding practices, structures, and priorities for those who develop and implement PC plans that further align with the HCBS rule person–centered planning standards.

For more information on these trainings please go to this site here, www.nydohpcptraining.com/events. We are developing and promoting a state–wide vision and universal understanding of person–centeredness across agencies providing and/or overseeing Medicaid HCBS. We´re building quality measurement and ongoing monitoring frameworks that link measurements to person–centered service plans and recipients' personal outcomes.

Now we´re going to move to the question and answer part of the session. There are additional resources that we will put up as a slide as well.

There´s a question here for the adult care facility. In the resident´s restaurant style dining room, are meals brought to the table or served at a common counter?

[Jennifer] As part of our food service team we do employ servers that go right to the table and take their order like they were at a restaurant.

[Mark] Great. Next question, for all the presenters: Are there examples of specific person–centered skills that are helpful in developing the person–centered plan? Maybe you all could take a shot at that one.

[Jennifer] I think just taking time, time to listen and time to come up with a comprehensive plan of what the individual´s needs and wants are. We do use the UAS assessment, so that does paint a nice picture of some of those needs as well as a nursing assessment. And just one–on–one conversation.

[Josephine] I think just basically what person–centered planning is focusing on, what the individual really wants, what they are looking to get out of the program, because they come to a medical model program. What are they looking to get out of our program? How can we meet those needs and their preferences?

[Ann] At ACT, we have an initial assessment that we provide to the family members and the actual participant dually for people with Alzheimer´s, dementia, and cognitive impairment. Sometimes it´s difficult for the people to verbalize what their past interests were or what they like. So, in addition to providing the participant an assessment we also have an extensive assessment process for the family members and the caregivers. But in addition to that too we really observe every day what their reactions are to every program we provide, so we´re able to, through observation and contact, figure out what will best fit their needs and then incorporate that into our care planning.

[Mark] Great. Thank you. There´s a question about the PowerPoint presentation being available. Yes, it will be available and posted on the website shortly

There´s a question about what portion of your clientele are military veterans, LGBT, or both. Do you have military veterans in your programs?

[Jennifer] We do. I would say maybe 10% of our population does have some sort of military affiliation or retirement benefits.

[Mark] What about LGBT?

[Josephine] We have a small percentage that are LGBT, and also, I would say we have military, but not necessarily from the US military.

[Ann] At ACT, we have a lot of participants who are experiencing PTSD and lined up with symptoms of Alzheimer´s and dementia, so we do see a lot of that in the younger male population. In addition, we do service the LGBTQ population.

[Mark] Great. What languages are spoken at the programs?

[Josephine] At Sunrise Adult Day Care we speak many languages. We speak Russian, Creole, Spanish, Italian, you name it we speak it. Mandarin, Cantonese.

[Mark] Great. Another question for the ACF. Does your current service plan include a goal section?

[Jennifer] We do have goals, and that´s why we do meet initially and every six months to talk about the individualized service care plan and to see if we´re meeting those goals or if those goals need to be changed.

[Mark] Great. Also, is the cooking of food and the opportunity for the member to take it home dependent on meeting your criteria?

[Ann] Yes. For social day programs we have a caterer that follows the instructions of the requirements based on NYSOFA and the regs, and we do not send food home with participants, so they eat on site and that´s it.

[Mark] Okay. What about the ADHC?

[Josephine] We do provide meals for those individuals that have difficulty preparing meals at home or may not have enough funding sources to be able to cook meals, so we do provide it for them. We keep it in the kitchen, in the warmers, and then just send it home with them when they´re ready to go or a cold sandwich.

[Josephine] Usually if they don´t have anyone to cook a meal for them at home, they don´t have food stamps, don´t have the resources to get their next meal.

[Mark] Great. Next question. Is there a separate quiet space for members who do not want to socialize or engage but want to be among others quietly? Is there a quiet room or a TV room?

[Ann] According to our regulatory requirements we do have a quiet area for our individuals where they can rest or relax. We also have a bedroom setup for those individuals that are frail and require some rest periods, we also have a room where they can go and rest, so they´re not always sitting on their wheelchairs.

[Jennifer] At the ACF we do have private apartments, so they do have the ability to go back to their apartments if they would like some alone time, and we do have various seating areas throughout the building, and common areas that can be used as well.

[Mark] Here´s a question about the ADHC program, I think. Participants do not have a choice each day but are offered many choices quarterly. We see the same meal each week for that cycle. How do we make this more individualized? That sounds like that needs some help. What would you recommend, to make that a more individualized service?

[Josephine] I would recommend they go speak to their administrator and change how they deliver meals to the registrants so that they can give more choices.

[Mark] Okay. Great.

[Anne] It´s always good to have a council meeting, too, with the dietary department, where the residents can actually voice their opinions and the chef can incorporate their choices into the menu.

[Mark] That´s a good point, too. How often do you provide a caregiver with an update to the care plan? How often is there a community update?

[Jennifer] We review initially in the ACF as well as every six months, and then any significant change to condition or–

[Mark] Can you talk a little bit about what a significant change would be?

[Jennifer] If a resident had a hospitalization, possibly traumatic event in their life, an injury, a fall, all of those could constitute a significant change.

[Mark] Okay. What about in the social day care program?

[Anne] So, for social day program a care plan is implemented within 30 days of admission while the family and Act staff are in touch very frequently. But in regard to formal updates, it´s every six months and the same for any significant change.

[Mark] Adult day health care?

[Josephine] We also care plan every six months and it´s reviewed quarterly by the nurses and the registrants. Families are invited to participate in the care plan meeting.

[Mark] Okay, great. Another question came in about what kind of specific training are you giving to your staff regarding the person–centered practice? As you look at this, what kind of training are you looking at for your staff?

[Jennifer] I have actually presented my PowerPoint presentation to all of our staff in our ACF as well as any regulatory changes that come down. We do hold a monthly staffing meeting to talk about any changes that may need to be addressed.

[Mark] Okay. What about Sunrise Adult Day Health Care?

[Josephine] We also provide a monthly staffing training and we do focus on person–centered planning. We´re trying to teach our staff to be more sensitive to what the person wants and how the person wants the service delivered as opposed to, "you´re on a bathing schedule on Monday at 9:00." Maybe the registrant doesn´t want the bath at 9:00. Maybe he wants it a little later in the afternoon. To create more sensitivity as to what the individual wants as opposed to what a nursing schedule looks like.

[Ann] At ACT, we also have monthly staff meetings and educational in–services, but I feel that more than anything on a daily basis this is a reminder from the program director, from myself as part of the administration, that person–centered care is the primary focus. Our quality of programming is extremely high. We have very high standards, and all staff is expected to keep up with those standards daily.

[Mark] Excellent. Okay. So, any other questions from the field? Any things you want to add to the event today? Final thoughts or things that you would recommend people think about, or look to?

[Ann] Well, for people dealing with a cognitive impaired population it´s really difficult sometimes for the individual to be expressive. People dealing with the aging population know this. It´s really important to keep an eye on that the personality is still in there and that the person just needs a different approach and a creative outlet to let us know how we can best provide for them. And it´s a privilege to do what we do for them each day, and I´m just very grateful to be in this position.

[Josephine] I would say, at Sunrise, we have always focused on the individual and our care has always been person– centered. A lot of the fears that we have in the industry is because of our very frail and cognitively impaired population. But I think that it´s important to note that we as professionals must implement safeguards for those individuals that would be put in an unsafe situation, that person–centered also means keeping the individual safe and safeguarded.

[Jennifer] Just a reminder that not everybody fits nicely into a box, and sometimes we have to think outside of that box, and with new technology and changes that are going on every day it´s that sometimes the way we used to do things does´nt work anymore, and to be able to come up with new and creative ideas.

[Mark] yeah, that´s great advice. I think we´re going to put up a slide on additional resources, and I want to ask everyone to take a look at those as well, and really sign–up for these additional education and training opportunities. The last bullet on that slide, that´s open and free to all.

Okay. Thanks everyone for your time. Please look at the additional resources. I want to thank my presenters for coming up today. We really appreciate your taking the time to be with us today.

[Presenters] Thank you.