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Health Advocacy Project

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Title: Health Advocacy Project


1
Health Advocacy Project
  • Improving the Health of Residents in Board Care
    Facilities
  • A Project of
  • Protection Advocacy, Inc.
  • Funded by the California Endowment

2
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.

3
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

4
Ethnicity of 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

5
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.

6
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.

7
Residents Rights, Service Entitlements,
Responsibilities in California Board Care
Homes for adult persons with mental disabilities
8
Admission Procedures No 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)
9
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.

10
  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.

11
Admission Agreements Must 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.

12
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.

13
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

14
Needs and Services Plans
15
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.

16
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.

17
Resident Rights
18
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.

19
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.

20
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.

21
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)

22
Tips for Family and Friends From 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
23
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

24
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?

25
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.

26
Important Telephone Numbers for
Complaints/Reports/Information
  • Community Care Licensing . . (619) 767-2339
  • Consumer Center for Health Education
  • and Advocacy
    1-877-734-3258
  • Patient Advocacy Program ............ (619)
    543-9998
  • Adult Protective Services . (619) 283-5731
  • Ombudsman .............. 1-800-640-4661
  • Protection Advocacy, Inc... 1-800-776-5746

27
Important Telephone Numbers for Information and
Referral
  • Info-Line - Central . (619) 230-0997
  • Info-Line North Coastal . (760) 943-0997
  • Info-Line North Inland .. (760) 740-0997
  • Info-Line Outlying . 1-800-227-0997
  • NAMI Albright Information and Referral
  • Center 1-800-523-5933
  • Mental Health Association .......................(
    619) 543-0412

28
Resident Councils
29
  • 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 -

30
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.

31
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.

32
Medi-Cal Services and Benefits
33
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

34
Fee for Service vs. Managed Care
Medi-Cal Choice (For SSI-linked Beneficiaries)
35
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.

36
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

37
How do I join a Medi-Cal Health Plan or find out
more information?
  • Contact a Health Care Options Counselor
  • Center City .. (619) 237-8506
  • El Cajon . (619) 441-6664
  • Escondido . (760) 480-3402
  • Kearny Mesa . (858) 694-8862
  • Lemon Grove . (619) 668-3784
  • Northeast (619) 464-5740
  • Oceanside .. (760) 754-5860
  • South Bay (619) 409-3296
  • Southeast (619) 266-3963

38
Fee for Service Medi-Cal
  • To Find a Doctor or Clinic, Call
  • Info-Line
  • Greater San Diego .. (619) 230-0997
  • North County Coastal (760) 943-0997
  • North County Inland (760) 740-0997
  • Other Areas .. (800) 227-0997

39
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

40
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

41
  • The best way to stay healthy is to
  • BE AN ACTIVE MEMBER OF YOUR HEALTHCARE TEAM

42
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.

43
Talking With Your Doctor
44
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.

45
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.

46
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.

47
Medications
48
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.

49
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?

50
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.

51
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.

52
CONFLICT RESOLUTION
53
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.

54
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.

55
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

56
Important Websites
  • Knox Keene / Managed Care Information
  • www.healthconsumer.org/managedcare.html
  • www.calpatientguide.org
  • www.hmohelp.ca.gov
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