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The Ohio Department of Aging

Ohio Department of Aging Aging Connection

Aging Connection

CONNECT TO | Programs & Benefits
September 2010

Helping nursing facility residents return to the community
Changes are coming to the nursing home resident assessment system

Nursing homes currently are required to assess resident needs in a comprehensive manner using a federal Resident Assessment Instrument/Minimum Data Set (MDS). A new version of the MDS, MDS 3.0, will be implemented Oct. 1, 2010. MDS 3.0 places more emphasis on talking with the resident and supports the right of individuals to reside in the most integrated setting possible to meet their needs. Resident input is critical to making him or her an active participant in care, so meaningful care plans can be developed.

Returning to the community

One section of the MDS, Section Q, is specific to helping the resident return to the community. Nursing home staff will ask all residents questions about their goals for returning home. Staff will ask at the time of the initial assessment (within 14 days after admission), quarterly and annually. When nursing home staff ask a resident if he or she wants to talk to someone about returning to the community, saying "Yes" means the resident wants more information, but it does not mean the resident has to leave the nursing home. Because a resident's needs and the services available may change over time, residents have the right to regularly learn about their options.

When a resident asks to speak with a professional about returning to the community, the response will trigger communication with the appropriate state and local agencies. A professional from the agency will call or visit the resident to learn about what services and supports the resident needs and to discuss options. The professional will then check on housing or home modification services in the community and check to see if there are support services available, such as help with medical and personal care, meals and transportation. The professional also will tell the resident whether he or she is eligible for programs that help pay for these services, such as Medicaid, Medicare or private insurance.

Ohio's system of long-term services and supports is built on a value for consumer choice and the way the new MDS is implemented will support person-centered values. In anticipation of MDS 3.0, state agencies began using similar questions in the pre-admission review process last year. The experience should help pave the way for successful implementation in October.

Ohio's aging network and long-term care ombudsman programs will have important roles in assisting residents with discharge planning, supplementing the work that nursing home social work staff is required to do. Ombudsmen are advocates for the rights of residents, and most regional ombudsman programs provide transition coordination services. Area agencies on aging provide long-term care consultation, an important first step to community living.

The MDS 3.0 questions and process present a more person-centered approach to choice and receiving services and supports in the community, in addition to promoting involvement of nursing home residents in care and service decisions that affect their lives.

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