| (A) Access and assistance staff shall develop criteria
for the inclusion or exclusion of agencies and programs in the resource
database or use criteria developed by other information, referral
and assistance entities. These criteria shall be uniformly applied
and published so that staff and the public will be aware of the scope
and limitations of the database.
(B) A standardized profile shall be developed for each
organization that is part of the community service delivery system.
(C) Information in the resource database shall be indexed
and accessible in ways that support the information, referral and
assistance process.
(D) Access and assistance staff shall use the AIRS/Infoline
Taxonomy to facilitate retrieval of community resource information
and to promote the reliability and consistency of information across
the service region and across the state.
(E) The resource database shall be updated through
continuous revision or at intervals sufficiently frequent to ensure
accuracy of information and comprehensiveness of its content.
(6) Information, Referral and Assistance Log.
(A) Access and assistance staff shall maintain a system
for collecting and organizing inquirer information that facilitates
appropriate referrals and provides a basis for describing requests.
(B) A unit of service is a client's initial request
for information or assistance. The area agency on aging shall have
a system for recording both initial inquiries and follow-up contacts
made by either the client or the agency.
(C) The area agency on aging shall use information
it records to identify service gaps and overlaps, assist with needs
assessments, support the development of products, identify issues
for staff training, facilitate the development of the resource information
system.
(7) Cooperation with Local Information and Referral
(I&R) Providers.
(A) In communities with comprehensive and/or specialized
information and referral (I&R) providers, including Area Information
Centers, when applicable, the area agency on aging shall develop cooperative
working relationships to build an integrated system of information,
referral and assistance which ensures broad access to services,
maximizes the utilization of existing resources, avoids duplication
of effort and encourages seamless access to community resource information.
(B) If the area agency on aging is designated by the
Texas Information and Referral Network as an Area Information Center,
the area agency on aging must meet the expectations of the designation.
(8) Professional Conduct.
(A) Access and assistance staff providing information,
referral and assistance services shall adhere to the standards of
conduct set forth by the Alliance of Information and Referral Systems
which are adopted by reference.
(B) Area agencies on aging are encouraged to seek and
maintain agency accreditation with the Alliance of Information and
Referral Systems.
(o) Care Coordination. The purpose of care coordination
is to assess the needs of a client and effectively plan, arrange,
coordinate and follow-up on services which most appropriately meet
the identified needs as mutually defined by access and assistance
staff, the client, and where appropriate, a family member(s) or other
caregiver.
(1) Program Design. The operational design of care
coordination is dictated by the needs of the area agency on aging
service area and includes a combination of levels of care. These levels
of care coordination include:
(A) Service Authorization without an assessment;
(B) Service Authorization requiring an assessment;
and
(C) Care Management, which includes the model of case
management as defined by the program entitled, Options for Independent
Living, as required by in Human Resources Code Chapter 101, Subchapter
C.
(2) Service Authorization. A process which identifies
a need for a service(s) and uses the direct purchase of service procedures
to obtain and initiate one or more services. There are two types of
service authorization. They include service authorization without
an assessment and service authorization requiring an assessment.
(A) Service Authorization Without an Assessment.
(i) Service authorization without an assessment may
be used to procure all services except home delivered meals, homemaker,
personal assistance, residential repair and respite services .
(ii) Service authorization without an assessment may
be performed by any area agency on aging-approved access and assistance
staff member either by phone or in person.
(iii) Service authorization without an assessment must
be based on a client intake completed by area agency on aging access
and assistance staff or by a qualified source. When authorizing congregate
meals a nutritional risk assessment must also be completed.
(B) Service Authorization Requiring an Assessment.
(i) Service authorization requiring an assessment may
be used to procure home delivered meals, homemaker, personal assistance,
residential repair and respite services .
(ii) Service authorization requiring an assessment
may be performed by any area agency on aging-approved access and assistance
staff member either by phone or in person.
(iii) In addition to completing the client intake and
nutritional risk assessment (home delivered meals), a modified assessment
must be conducted which may include:
(I) TDHS Form 2060; or
(II) Service appropriate assessment.
(III) Area agency on aging access and assistance staff
may conduct the assessment, procure it or accept it from a qualified
source.
(C) Care Management. Care management is a process that
assists clients with multiple needs by developing and implementing
comprehensive plans of care.
(i) Care management services may be provided only to
persons age 60 years and older and/or his/her family member or other
caregiver, with priority given to those:
(I) who have recently suffered a major illness or health
care crisis or have recently been hospitalized and need additional
attention during the recuperation period in accordance with Human
Resource Code, Chapter 101, Subchapter C, relating to Options for
Independent Living;
(II) who live in a rural area;
(III) who are moderately to severely impaired in activities
of daily living and instrumental activities of daily living;
(IV) have insufficient caregiver support; or
(V) who are in great economic or social need, particularly
low-income, minority older persons.
(ii) Care management must include the following:
(I) Comprehensive Client Assessment: A needs assessment
may be provided, procured or accepted from a qualified source and
must include the following components:
(-a-) cognitive status (if applicable);
(-b-) emotional status (if applicable);
(-c-) physical environment (requires on-site evaluation);
(-d-) social environment, including informal or family
support;
(-e-) physical status;
(-f-) economic status;
(-g-) self-care capacity; and
(-h-) services presently received.
(II) Care Plan. Care Managers shall develop a written
plan that is based upon the client's preferences, as supported by
identified priority needs and within available public/private resources.
The care plan must specify the amount, frequency and duration of each
service to be provided and identify the outcomes to be achieved.
(III) Service Arrangement. Care managers shall arrange
for services identified in the care plan to begin at the earliest
possible date, consistent with the capacity of the provider and may
include, but is not limited to:
(-a-) exploring the availability and quality of services,
eligibility criteria and accessibility of a service to the client;
(-b-) making and documenting referrals to community
service agencies;
(-c-) working with volunteers to provide services;
(-d-) working with family and friends of the client
to help achieve specific service goals; and
(-e-) authorizing services deemed appropriate by the
area agency on aging using direct purchase of service procedures.
(IV) Monitoring/Follow-up Activities. Care managers
shall conduct monitoring and follow-up activities which include verifying
service delivery, determining the extent to which services meet the
needs and expectations of the client, and where necessary, advocating
for improvements in service delivery. Monitoring shall include at
least monthly contacts with the client and a home visit not Cont'd... |
