Health Advocacy Project

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Health Advocacy Project

• Improving the Health of Residents in Board Care
  Facilities
• A Project of
• Protection Advocacy, Inc.
• Funded by the California Endowment

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California Board Care Homes
History / Background

• Intended to insure a level of care and services
  in the community which is equal to or better than
  that provided by the state hospitals.
• Intended to provide safe, high quality,
  supervised living environments with services
  necessary to meet the residents identified,
  specific needs.
• Intended to insure continuity of care between the
  medical-health elements and the supportive
  care-rehabilitative elements of Californias
  health systems.

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Licensed Facilities

• Statewide
• Facilities Residents
• Adult Residential 4,751 39,444
• (Community Care Licensing Data)
• Adults w/ Mental Disabilities 2,700 28,000
• (CRCA Data)
• San Diego County
• Adult Residential 448
• Adults w/ Mental Disabilities (estimated)
  84

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Ethnicityof Board Care Residents

• of M/H of BC
• Population Population
• African American 18.2 21.3
• American Indian .7 .7
• Asian 1.6 3.2
• Caucasian 56.4 48.2
• Hispanic 13.9 20.3
• Other 9.2 6.3

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Surveys of Residents According to 1999 report to
the San Diego Coalition for Mental Health

• 24 (N170) of residents surveyed had complained
  of a physical illness, yet received no follow-up
  to their complaint.
• 56 (N200) had not seen a physical health doctor
  since living at the facility.
• 46 (N167) reported that there had been physical
  violence in the home.
• 14 (N150) reported that sexual abuse had
  occurred in the home.
• 83 (N175) reported no involvement in house rule
  making or problem solving.

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Surveys of Residents According to a California
Network of Mental Health Clients survey of 215
residents in 16 Southern California homes

• gt 50 of the residents had not been allowed to
  visit the home prior to being placed there.
• gt 50 of the residents had been placed in the
  home from a hospital, without benefit of a
  discharge planning process.
• gt 60 of the residents were unaware that they
  could register a complaint with Community Care
  Licensing.
• gt 50 of the residents did not know how to
  contact the local Patients Rights Advocate.

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Residents Rights,Service Entitlements,
Responsibilitiesin CaliforniaBoard Care
Homesfor adult persons with mental disabilities
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Admission ProceduresNo client may be admitted
prior to a determination of the facilities
ability to meet the needs of the client, which
must include an appraisal of his/her individual
service needs.(Title 22, California Code of
Regulations, Section 85068.1)
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Before admission the following services must be
provided

• A medical assessment, completed by a qualified
  medical professional.
• A mental health intake assessment, completed by a
  licensed mental health professional.
• An assessment of the clients need for personal
  assistance and care, by determining his/her
  functional capabilities, completed by the
  facility staff.

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1. The facility staff must complete a written Needs
   and Services Plan.
2. The person is allowed to visit the facility with
   his/her family, friends, and/or representative.
3. The person is interviewed by the facility staff
   and is provided with information about the
   facility, including information contained in the
   admission agreement.
4. An admission agreement must be obtained.

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Admission AgreementsMust Specify

• Basic Services
• Available Optional Services
• Payment Provisions
• Refund Conditions
• Conditions for Termination
• Policies for Family Visits and Communications
• General Facility Policies
• Current arrangements with the client regarding
  the provision of food service.

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Medical Assessments must include

• A physical exam which indicates the primary and
  secondary diagnosis, if any.
• Current medical status.
• Prior medical services and history.
• Communicable diseases exam.
• Identification of the clients special problems
  and needs.
• Identification of prescribed medications being
  taken.
• Identification of physical restrictions effecting
  the clients ability to participate in the
  facility program.

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Functional Capabilities Assessments must
include

• Activities of Daily Living (Eating, Bathing,
  Dressing, Grooming, etc.)
• Ambulation
• Vision, hearing, communication
• Medical history and conditions
• Need for prescribed and non-prescribed
  medications
• Mental and emotional conditions
• Socialization and cognitive status
• Propensity for harmful behaviors
• Ability to manage his/her own finances
• The assessment must be in writing and
  must be used in developing the Needs and
  Services Plan

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Needs and Services Plans
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Development of the NSP shall involve

• The client, or his/her authorized representative,
  if any.
• Any relative participating in the placement.
• The placement or referral agency, if any.
• The person responsible for facility admissions.

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Needs and Services Plan

• The written NSP shall include the clients
  desires and background, obtained from the client,
  the clients family or his/her authorized
  representative, if any, and licensed
  professional, where appropriate, regarding
• Entrance to the facility.
• Specific service needs.
• Written medical assessment.
• Mental and emotional functioning.
• Written mental health intake assessment.
• Written functional capabilities assessment.
• Facility plans for providing services to meet the
  individual needs of the client.
• The written NSP shall be updated as frequently as
  necessary to ensure accuracy and to document
  significant occurrences that result in changes in
  the clients physical, mental and/or social
  functioning.

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Resident Rights
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Residents Have the Right

• To receive prompt and satisfactory medical and
  dental care, including
• Health and Mental Health services that meet ones
  age, language and background needs.
• Safe transportation to ones medical or dental
  service provider, arranged by facility staff.
• Attendance at community health and mental health
  programs of ones choice.
• Facilities are required to develop and
  implement a plan which ensures that assistance is
  provided to residents in meeting their medical
  and dental needs.

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Residents Have the Right

• To have access to individual storage space for
  personal use.
• To have reasonable access to make and receive
  confidential telephone calls.
• To receive unopened mail and correspondence.
• To practice ones religion and attend religious
  services of ones choice.
• To socialize with all other residents in common
  areas.
• To participate in recreational activities.
• To a clean and pleasant living environment with
  as much freedom as ones safety and the safety of
  others permits.
• To be treated with respect and dignity, free from
  physical or emotional abuse or neglect.
• To privacy in every day life situations.

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Residents Have the Right

• To actively participate in the development of
  ones Needs and Services Plan.
• To keep and spend a reasonable sum of money.
• To wear ones own clothes.
• To be free from discrimination on the basis of
  disability, race, color, sex, age, sexual
  preference, marital status, economic and familial
  status.
• To exceptions or changes to the facility rules,
  policies, or practices when such exceptions or
  changes are necessary because of a persons
  disability.
• To freely leave and return to the facility,
  within those time restrictions necessary for the
  protection of all residents.
• To be provided with oral and written information
  about ones medication.

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Rights that may be limited for those residents
who have an LPS conservator

• To possess and control ones own money.
• To refuse medications.
• To receive or reject medical care or
  health-related services.
• To move from the facility (within the terms of
  the admission agreement)

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Tips for Family and FriendsFrom A Mothers
Perspective on Board and Care An interview with
Barbara Castle Board and Care Quality Forum
Volume 5, Number 5 Published September/October
2002
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Finding a Board and Care Home

• Dont rely on hospital social workers and
  discharge planners.
• Make appointments and visit some facilities.
• Know that there arent enough homes to begin
  with, so be proactive

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Things to Look For

• Location Proximity to public transportation and
  necessary healthcare services.
• Supervision - Does the facility seem to provide
  adequate staffing supervision?
• Structure - Are there structured activities,
  programs, outings, etc.?
• Are the staff courteous and respectful when
  interacting with residents?
• The manager should be open to listening to the
  residents about conditions and things happening
  in the home.
• Does the facility welcome/encourage family and
  friends involvement and input?
• How do the other residents feel about the
  facility?

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Be a positive influence

• Try to establish good communication and a
  positive relationship with the operators.
• Avoid adversarial, confrontation with the staff
  and/or operator, if at all possible.
• Spend time at the facility on a regular basis.
• Get to know the other residents and their
  families and friends.
• Try to do anything you can to create a
  supportive, safe environment.

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Important Telephone Numbersfor
Complaints/Reports/Information

• Community Care Licensing . . [phone]
• Consumer Center for Health Education
• and Advocacy
  1-877-734-3258
• Patient Advocacy Program ............ (619)
  543-9998
• Adult Protective Services . [phone]
• Ombudsman .............. 1-800-640-4661
• Protection Advocacy, Inc... 1-800-776-5746

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Important Telephone Numbersfor Information and
Referral

• Info-Line - Central . [phone]
• Info-Line North Coastal . [phone]
• Info-Line North Inland .. [phone]
• Info-Line Outlying . 1-800-227-0997
• NAMI Albright Information and Referral
• Center 1-800-523-5933
• Mental Health Association .......................(
  619) 543-0412

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Resident Councils
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• Every licensed community care facility, at
  the request of a majority of its residents,
  shall assist residents in establishing and
  maintaining a resident oriented facility council.
  The council shall be composed of residents of the
  facility and may include family members of
  residents of the facility. The council may, among
  other things, make recommendations to facility
  administrators to improve the quality of daily
  living in the facility and may negotiate to
  protect residents rights with facility
  administrators.
• - Health and Safety Code, Section 1520.2 -

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Resident Council Requirements

• Facility administration must assist residents in
  establishing and maintaining a council.
• Facility staff must provide assistance to
  residents in attending council meetings.
• Notices of meetings must be posted and residents
  must be encouraged to attend by staff in a manner
  appropriate to the residents disability,
  including but not limited to verbal
  announcements.
• The council shall be composed of residents of the
  facility and may include family members of
  residents.

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Resident Council Meeting Requirements

• The facility must provide space for council
  meetings.
• Meeting notices, meeting times, and
  recommendations from the council must be
  documented.
• In order to permit free exchange of ideas, at
  least part of each meeting shall be conducted
  without the presence of any facility personnel.
• A facility which fails to provide a resident
  council at the request of a majority of the
  residents, and/or to operate a council in
  accordance with regulations, may be subjected to
  civil penalties.

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Medi-CalServices and Benefits
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Medi-Cal Pays For (among other things)

• Doctor Visits
• Adult Day Health Care
• Personal Care (IHSS)
• Emergency Services
• Transportation to Health Services
• Diagnostic Tests
• Surgical Procedures
• Nursing Home Stays (Excluding Institutions for
  Mental Disease)

• Medical Supplies
• Durable Medical Equipment
• Occupational Physical Therapy
• Outpatient Drug Abuse Services
• Prescriptions
• Hospitalization
• Dental Services

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Fee for Service vs. Managed Care
Medi-Cal Choice (For SSI-linked Beneficiaries)
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How a Medi-Cal Managed Care Plan Works

• You choose a Primary Care Doctor or Clinic from a
  list.
• You must go to the Primary Care provider first
  They will refer you to a Plan specialist, if
  necessary.
• If youre not happy with your Primary Care
  provider, you can call the Member Service
  Department and choose a different provider.
• You need to go to a Plan Pharmacy for
  medications.
• A 24-hour, toll free number must be available to
  call with questions about your care.
• You may leave the Health Plan and choose a
  different Plan, at certain times.
• There are no costs to you and no co-payments.

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Healthy San Diego Medi-Cal Health Plans

• Blue Cross of California
• Community Health Group
• Health Net
• UCSD Health Plan
• Sharp Health Plan
• Universal Care
• Kaiser

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How do I join a Medi-Cal Health Plan or find out
more information?

• Contact a Health Care Options Counselor
• Center City .. [phone]
• El Cajon . [phone]
• Escondido . [phone]
• Kearny Mesa . [phone]
• Lemon Grove . [phone]
• Northeast [phone]
• Oceanside .. [phone]
• South Bay [phone]
• Southeast [phone]

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Fee for Service Medi-Cal

• To Find a Doctor or Clinic, Call
• Info-Line
• Greater San Diego .. [phone]
• North County Coastal [phone]
• North County Inland [phone]
• Other Areas .. [phone]

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Positives

• Fee for Service
• Choice of doctors, clinics, service providers
• No referral necessary for specialists
• Maintain existing relationship with providers

• Managed Care
• Provides a health home for the person and their
  family
• Access to additional services (i.e. 24 advice
  s, member advocate, education programs)
• Provider directory and referral information
  readily accessible.
• Additional rights under Knox Keene Act

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Negatives

• Fee for Service
• Difficulty finding providers who take Medi-Cal.
  (Compounded if second opinion needed)
• Consumer protections only through State D.S.S.

• Managed Care
• Access to specialists only through Primary Care
  doctor
• Access to providers restricted to Plan
• May need to disenroll if placed in an IMD

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• The best way to stay healthy is to
• BE AN ACTIVE MEMBER OF YOUR HEALTHCARE TEAM

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Understand Your Responsibilities

• Keep your appointments and be prepared.
• Follow your doctors instructions.
• Take medicine as prescribed.
• Keep your doctor informed as to your progress.
• Know how to contact your doctor.
• Have a plan for what to do if you have problems.

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Talking With Your Doctor
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Be Ready to Give Information

• Tell your doctor what you think he or she needs
  to know, even if it makes you feel uncomfortable.
• Bring a health history list with you.
• Bring a list of any medications you are taking,
  including dosage and how often you are taking
  them.
• Bring a list of any herbal products or
  alternative medicines you are using.
• Bring any other medical information, such as test
  results, or other records.

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Ask Questions and Get Information

• If you dont understand something, speak up.
• Make a list of questions ahead of time, with the
  most important questions first.
• Bring someone with you.
• Ask your doctor to draw pictures, and/or write
  things down.
• Take notes.
• Ask if there are any written materials or
  handouts.
• Ask if you can call back later with any questions
  and find out to whom you should speak.

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After you leave the doctors office

• If you have questions, or forgot to tell the
  doctor something, call back and speak with
  someone.
• If your symptoms get worse, call.
• If you have any problems with your medicine,
  call.
• If you need to make an appointment for tests or
  to see a specialist, make the appointment.

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Medications
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Before starting on any medication, tell your
doctor

• The names of all medication you are currently
  taking, both over-the-counter and prescription,
  as well as herbal or alternative types of
  treatment.
• Make sure your doctor is aware that
  over-the-counter medications have to be
  prescribed in a board and care setting.
• Any allergies or adverse effects you have
  experienced from any medications youve taken in
  the past.
• Any concerns you have about taking medication.

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When you are prescribed medication, ask your
doctor

• What is the name of the medication?
• What is the medication supposed to do for me?
• What is the dosage?
• What are the possible side effects and what
  should I do if they occur?
• What should I do if I miss a dose?
• What should I do if I accidentally take too much?
• Are there food, drinks, or other medicines I need
  to avoid while on the medication?
• Can I get any written information about the
  medicine?

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After youve started on medication, make sure to
tell your doctor

• How you are feeling on the medication.
• About any problems or side effects you have
  experienced.
• About any new medication another doctor may have
  prescribed for you, or over-the-counter drugs you
  have taken.

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About your medication, remember

• Take only the medicine your doctor prescribes for
  you. Dont take anyone elses medicine.
• Know the major side effects of your medicine and
  call your doctor right away if you are having
  problems. Dont wait!
• Take the medicine as you and the doctor have
  agreed, not how you think it should be taken.
• Order refills before you run out. Always plan
  ahead.
• Alcohol and street drugs dont mix with your
  medication.

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CONFLICT RESOLUTION
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What can you do if

• You have a problem with your health plan or
  Medi-Cal.
• Your care is denied, delayed, or terminated.
• You disagree with your doctor about what is best
  for you.
• You are told you cant see a specialist, receive
  more visits, or get certain medicines.

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You have a right to

• Contact your health plan or Med-Cal and complain.
• Receive written explanation whenever service is
  denied, reduced, delayed, or stopped.
• Receive a notice before ongoing services are
  stopped or reduced.
• Continue to receive benefits while your complaint
  is being heard.
• Have a hearing before an Administrative Law
  Judge.
• Report the problem to the State.
• Change to a new Health Plan.

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Important Telephone Numbers

• Healthcare Options 800-430-4263
• (Healthy San Diego Enrollment)
• Managed Care Ombudsman 888-452-8609
• (State Patient Advocate)
• State Fair Hearings (DSS) 800-952-5253

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Important Websites

• Knox Keene / Managed Care Information
• www.healthconsumer.org/managedcare.html
• www.calpatientguide.org
• www.hmohelp.ca.gov