PROCEDURES MANUAL

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF ELDER AFFAIRS

Deval Patrick

GOVERNOR

Ann L. Hartstein

Secretary

EXECUTIVE OFFICE OF ELDER AFFAIRS

Procedure Manual

Printing paid through a grant from the Centers for Medicare & Medicaid Services

Revised March 2013 Page 1 of 62

A - REGIONAL SHINE PROGRAM PROCEDURES...... 4

Regional directors’ LIAISON ROLE...... 5

MONITORING/ COUNSELOR SUPERVISION...... 5

REGIONAL SHINE PROGRAM DIRECTOR RESIGNATIoN ...... 7

Departing Regional Director Procedures...... 8

TELEPHONE AND E-MAIL PROCEDURE...... 9

PROGRAM GOALS AND STANDARDS...... 10

RECORD KEEPING AND CONFIDENTIALITY ...... 11

CONFLICT OF INTEREST...... 12

OUTREACH TO THE REFERRAL NETWORK FOR ...... 13

THE SHINE PROGRAM ...... 13

PROGRAM BROCHURES AND STATIONARY...... 13

MONITORING OF REGIONAL SHINE PROGRAMS BY STATE SHINE STAFF...... 14

Reports/Workplans/Performance...... 14

PROHIBITION AGAINST PROVIDING PRIVATE INSURANCE APPLICATIONS INCLUDING HMO, MEDIGAP AND LONG TERM CARE 17

MEDICAL EMERGENCY DURING HOME VISIT...... 17

Criminal Offender Record Information (CORI)...... 18

HOME VISIT PROTOCOLS...... 18

Unique ID Numbers...... 20

Agent/Company Resolution...... 20

B - RECRUITMENT & TRAINING PROCEDURES...... 21

RECRUITMENT OF SHINE VOLUNTEERS...... 22

RECRUITMENT OF SHINE VOLUNTEERS-...... 25

...... 27

CERTIFICATION TRAINING...... 27

COUNSELOR RE-CERTIFICATION...... 28

TECHNICAL ASSISTANCE...... 28

SHINE CERTIFIED TRAINERS...... 29

TRAINING ROLES AND RESPONSIBILITIES...... 30

CERTIFICATION TRAINING ...... 34

C - VOLUNTEER MANAGEMENT PROCEDURES...... 36

de-CERTIFICATION OF COUNSELORS...... 37

COUNSELOR RESIGNATION...... 38

CounselorDATABASE...... 39

COUNSELOR SCHEDULES...... 39

SPEAKERS BUREAU...... 40

SHINE CLIENT INFORMATION...... 41

SITE MANAGEMENT PROCEDURE...... 41

COUNSELORS AS MENTORS...... 42

MONTHLY REPORTING...... 42

D - REGIONAL SHINE PROGRAM PLANNING AND REPORTING...... 44

REGIONAL REPORTING...... 45

REGIONAL DIRECTOR WORK PLANS...... 46

Quarterly Work Plans...... 47

PROGRAM OUTREACH...... 48

MEMORANDUM OF UNDERSTANDING...... 48

QUALITY ASSURANCE...... 50

in the development stages: summary form...... 50

shine regional PROGRAM BUDGET...... 50

E – PUBLICATIONS & PUBLICITY...... 51

PUBLICITY...... 52

F - OUTREACH AND EDUCATION...... 54

Medicare Advantage plan withdrawal PACKET...... 55

Integrating SHINE and MAP Services to Achieve Program Improvement Goals...... 56

Additional Areas for Collaboration...... 57

Health Benefits University...... 61

INFORMATION AND REFERRAL FOR MEDICARE BENEFICIARIES PROJECT- now incorporated into HBU list 62

A - REGIONAL SHINE PROGRAM PROCEDURES

Regional directors’ LIAISON ROLE

/ Procedure # A-1
November, 1997
Revised July 2008
The SHINE Regional Director serves as the link between SHINE counselors and the State SHINE Staff. The SHINE Regional Director also reports on new developments in programmatic policies and standards to his or her supervisor at the regional lead agency. (See Appendix #1 Regional SHINE Director Job Description).
To support these functions, SHINE Regional Directors and State SHINE staff meet regularly to discuss programmatic standards and health benefits information, counseling techniques, assistance methods, outreach and referral and other topics. The Regional Director then meets with the counselors and the lead agency supervisor/contact person to up-date them on relevant matters.
State SHINE Staff may also communicate with the Lead Agency Director as needed. Annually, the State Director invites the Lead Agency Directors to a meeting to present SHINE program accomplishments and upcoming funding and expectations.

MONITORING/ COUNSELOR SUPERVISION

/ Procedure # A-2
November, 1997
Revised June 2008
Regional Directors are responsible for monitoring the technical skills and accuracy of their counselors and providing on-going training for skills improvement. Several tools are needed to perform this task.
Counselors will use two types of forms:
  • a Client Contact Form and
  • a Public and Media Activity Form (See Appendices #2 Client Contact Form, #3 Public and Media Activity Form)
The SHINE Regional Directors will train and refresh counselors as needed to properly use these forms to record counseling activity and cases. It is
essential that SHINE Regional Directors spend a sufficient amount of time in the field, supervising counselors by joining counseling meetings with clients to observe the counselors’ techniques.
It is the responsibility of the Regional Director to recruit counselors for the lead agency site to ensure that he or she spend adequate time administering, performing outreach and supporting the counselors. Additionally, Regional Directors should recruit volunteers to provide administrative services to the program. This volunteer may or may not be SHINE trained. (See Appendix # 10 Lead Agency Clerk Job Description)
Counselor update training, on-site supervision and modeling, reviewing Client Contact Forms and recertification exams are ways to provide supervision. Once a poor practice is identified, the Regional Director arranges to communicate findings and recommendations to the counselor. Depending on the situation, the Regional SHINE Director’s options are to retrain or decertify the counselor.
Counselors are required to become recertified every year. The Trainers Work Group review materials for update training, creates a recertification exam which is administered to all counselors in March. A score of 80% or higher is passing .A counselor with a 79% score or below may receive partial or complete retraining and recomplete the exam, or may be decertified upon consultation with the Regional Director. Counselors may appeal decertification to the State SHINE Director.

REGIONAL SHINE PROGRAM DIRECTOR RESIgNATIoN

/ Procedure # A-4
November, 1997
Revised June 2008
SHINE Regional Directors are required to inform the State SHINE Director and the Lead Agency Director of their intent to resign in writing. SHINE Regional Directors should provide as much notice as possible, but at least a minimum of two weeks’ notice of resignation. (See Addendum for steps on managing the Regional SHINE Program during transition).
The Lead Agency Director should immediately advertise the vacancy and begin the interview process. The Lead Agency Director or their designee will be responsible for overseeing the program functions until a new SHINE Regional Director is named. The State SHINE Director can help said individual to know what projects need follow-up and ongoing attention during the search and
interview process. The State SHINE Director should be notified as soon as a new Regional SHINE Program Director has been hired and the expected start date.
Many Regional SHINE Programs temporarily hire one or more volunteer counselors to serve as Acting SHINE Regional Director during the search and hiring process, as counselors will have a need for ongoing technical assistance. Also, unforeseen events may occur that require coordination of outreach within the Regional SHINE Program. To avoid disruption in services, it is essential for all Regional SHINE Programs to develop a corps of volunteers and an administrative clerk who work in the Regional office fielding consumer calls, conducting speaking engagements and organizing on-going training meetings monthly.
During the hiring process, if a program has no SHINE Regional Director, ongoing technical assistance can be obtained, from mentor counselors, SHINE Regional Directors and State SHINE staff. The State SHINE Staff will schedule an exit interview with the Regional Director.

Departing Regional Director Procedures

/ Procedure # A-4 (ADDENDUM)
Protocol for departing SHINE Regional Directors include:
  • Notify immediately, State SHINE Staff of planned departure.
  • Coordinate schedule for next three months of counselor meetings, with the State SHINE Director .to ensure coverage.
  • Provide up to date counselor roster with mailing addresses and telephone numbers to State SHINE Manager of Field Operations and local site manager to conduct mailings, if need be, before the next Director is hired.
  • In collaboration with the Lead Agency Director, develop procedures to handle the transition and inform the counselors by mail and e-mail

If a counselor training was scheduled, the Manager should identify the recruited and approved persons waiting for the certification training and confirm that they are still planning to attend the pending certification. The applications must be mailed to the State manager of operations. All new recruits should have a counseling location identified to which they will report once certified.
In the absence of the Regional Director, State SHINE Staff shall prepare and mail out the orientation packets to these counselors directly. The host trainer would be the new recruit’s contact during the course of the training.
The departing SHINE Regional Director must identify staff or a mentor counselor from the program and assign the task to orient and train the new counselor once he/she is certified. Mentors allow the new counselor to shadow them for 6 hours during their counseling sessions and will observe the new counselor during 6 hours of their counseling sessions. This observation will afford them the opportunity to provide feedback, provide technical assistance and support. Regional staff will ensure that the new recruit knows the schedule for the upcoming meetings and any other information that will help the new counselor learn about the program, feel welcome and supported.
The mentor counselor will also play an important role in orienting the new SHINE Regional Director about the program staff, placements, routines and traditions. They will also:
  • Identify all scheduled speaking engagements
  • Help to assign counselors to cover local events
  • Show those speakers how to pick up handouts for events.
(For larger regional events, such as HBU, or more challenging technical events, State SHINE Staff will cover or find another trainer)
  • Develop a rotation of volunteer staff that can take messages and return calls at Regional office.
  • Attend the Regional Director monthly meeting and communicate the information to the counselors during the next meeting, until a Regional Director is chosen. State staff will assist with the trainings as needed.

TELEPHONE AND E-MAIL PROCEDURE

/ Procedure # A-5
January 17, 2001
All SHINE Regional SHINE Programs will advertise 1-800-AGE-INFO (1-800-243-4636) as the primary number along with their local number on all program materials.
Regional SHINE Programs must advertise that the phones will be answered during the regular business hours of the host site. These times should be posted on all program materials and on the phone message system. Regional Directors are expected to arrange for daily volunteer coverage of the regional office during these times.
Voice mail or answering machine messages should identify the program and the hours of operation - example
“You have reached the SHINE Program; we are unable to take your call at this time. Please leave your name, phone number and a brief message and we will return your call, or you may contact your local Council on Aging to schedule an appointment with a local SHINE Counselor. Our regular business hours are______”.
Messages must be cleared daily and all calls should be returned within 24 hours during non-crisis times. During crisis times (ex., the Open Enrollment Period) Regional SHINE Programs should alter the voice message to direct callers to their local counseling site or give other pertinent information such as the 24 hour/day phone number of 1-800-medicare.
Regional Directors should clear their e-mail daily. State SHINE Staff will use e-mail to electronically transmit information to the Regional SHINE Programs. The clerical volunteer and SHINE counselors in the Regional Office should also be instructed on the process for retrieving e-mail messages in the absence of the Regional Director.

PROGRAM GOALS AND STANDARDS

/ Procedure #A-6
November, 1997
Revised July 2008
Regional SHINE Program Directors will keep on file their SHINE annual work plan and attachments and the SHINE Program service elements. These documents represent local goals and minimum program standards and procedures.
Regional SHINE Program Directors will have a file for each counseling site in their Regional SHINE Program. This file will include the signed Memorandum of Understanding (MOU)(See Appendix #26), additional support agreements given by member agencies, staff contacts, schedules of SHINE volunteers at the agency, newsletters, etc.

RECORD KEEPING AND CONFIDENTIALITY

/ Procedure # A-7
November, 1997
Revised July 2008
The Executive Office of Elder Affairs has Privacy and Confidentiality Regulations (651 CMR 2.00 et. eq.) which apply to all holders of personal data including all persons or entities who enter in contracts or agreements with the Executive Office of Elder Affairs.
Personal Data means any data regarding an individual including personal identifiers, and including, but not limited to information that relates to support or assistance rendered to the individual, and any medical, financial, social, or psychological data which is normally contained in case files.
A holder of personal data shall not collect, maintain, or disseminate any personal data other than that which is essential for the performance of his/her function. Additionally, the holder shall identify the kinds of data that will be held, and assure the individual that such data is essential for the performance of their SHINE duties. Those statements of identification and assurance are included in the Summary of Confidentiality Procedures (See Appendix #5 Summary of Confidentiality Procedures) that the SHINE Counselor must provide to each of the clients.
In more detail, the Summary of Confidentiality Procedures performs two functions related to the confidentiality regulation: first, it identifies the types of personal data information that is needed, the expected uses of such information, and the length of time such information shall be held before it is purged, and second, it assures that the holding of such data is essential for the performance of the SHINE function.
The obsolete data (see Client Contact Forms Appendix #2, Authorization Forms Appendix #17) need to be filed securely, safe from water or fire and then transferred on a monthly basis to the Regional SHINE Director, who will review the Client Contact Forms and store them safely. Annually, all client forms must be securely boxed and stored in a safe dry place.
Data collected for SHINE purposes cannot be used for any other purpose such as mailing lists for the host member agency. Also, only those persons whose duties require access to the SHINE forms may have access. No other person is permitted to see these documents, even staff of the host member agency.
Once per year a representative from the State SHINE Office and the Regional SHINE Program Directors shall schedule a review of the data system held by the Regional SHINE Program Director. They shall review the system for compliance with the requirements for storage (security and duration).
The State SHINE Office representative will verify that the system is in compliance with these privacy and confidentiality regulations. If the system is not in compliance, a plan of action will be written. Currently, regulations require that records for the SHINE Program be kept for 3 years from the end of the calendar year in which any record is begun.

CONFLICT OF INTEREST

/ Procedure # A-8
November, 1997
In order to assure that SHINE counselors provide unbiased, objective counseling and information to clients, an individual cannot be a counselor if he or she or a member of his or her family is employed by a health insurance or prescription drug company.
Additionally, a SHINE counselor cannot request or receive payment from a client or client’s family, and cannot receive financial compensation as a result of referring clients to particular companies or service providers.
The counselor shall sign an agreement attesting to such compliance. See attached #34 Conflict of Interest statement.
New counselor applications shall be sent to the Manager of Field Operations/Training Coordinator to review for potential conflict of interest. The final arbiter in those situations is the State SHINE Director. Regional Directors should seek assistance from the SHINE Director whenever unusual profiles of counselors arise.

OUTREACH TO THE REFERRAL NETWORK FOR

THE SHINE PROGRAM

/ Procedure # A-9
November, 1997
Revised July 2008
Regional Directors should routinely post and advertise information about the SHINE Program, upcoming changes for Medicare beneficiaries and ways to access to counseling services. The Regional network should include, but not limited to Hospice Agencies, VNA, Veterans Agents, Hospital Discharge Planners, Social Workers, clinics, physicians, disability communities churches, temples, housing managers etc. Information about upcoming trainings, brochure, and other pertinent materials should be included. SHINE Brochures should list the telephone number of the Regional SHINE Program and all the member agencies.
In SHINE Program regions, consumers may call either their local SHINE office or the Regional Director, who will then refer the caller according to the schedule and roster he/she maintains. It is extremely important that the Director and the member agencies agree upon a referral system, understand the system and present that information clearly to all the referral resources and consumers when they call a site or the Regional office.

PROGRAM BROCHURES AND STATIONARY

/ Procedure # A-10
January, 2002
Revised July 2008
Regional SHINE Programs should have a program brochure. Regional Directors have the freedom to customize their brochures to reflect their Regional SHINE Program. However, all brochures must have the following information and design.
  • Color – preferably blue cover with white print on the outside; inside white with black print.
  • SHINE Logo
  • SHIP Logo
  • Lead Agency name, address, local telephone number(s), TTY, and fax number.
  • Panel on SHINE – what it is, services provided.
  • List of member agencies.
  • Phone#: 1-800-AGE-INFO and 1-800-243-4636
  • Website:
  • Must include the statement “This publication paid for in part by a grant from CMS”

Regional SHINE Program letterhead is optional. Program letterhead should include:
  • The SHINE Program and SHIP logo with address of lead agency and a list of member agencies

MONITORING OF REGIONAL SHINE PROGRAMS BY STATE SHINE STAFF

/ Procedure: # A-11
November 1997
March 2002
Revised July 2008

Reports/Workplans/Performance

State SHINE Staff monitor activities of each Regional SHINE Program by attending counselor meetings and training sessions, reviewing records maintained at the regional office site, monitoring work plans, activity reports on counseling and outreach, and by meeting with the lead agency director and staff as indicated. Details for each process are printed below. The State SHINE Staff maintains a Record of Monitoring Regional SHINE Programs for each contractor. (See Appendix #7 – Record of Monitoring Regional SHINE Programs by State SHINE Staff.)
Report on Program Activities for Contracts Commencing On and After
4-1-02
All SHIP programs funded by CMS participate in a national performance reporting system (NPR) that has a goal of demonstrating the value of the SHIP programs to justify financial support provided to it by CMS, as well as other federal, state and private funders. The NPR system collects state level and local level information to produce a comprehensive picture on how well the SHIP is serving individual beneficiaries, their caregivers, other professionals via one on one counseling, public forums, outreach and process methods. Instructions and sample forms are in the SHIP NPR Training Manual.
As a quick reference, a summary of the SHINE program reporting system is described below.
Client Contact Activity
Counselors are required to use a client contact form for every face-to-face encounter with a beneficiary. Regional SHINE staff collects these reports and the data is entered regularly and by the month after each quarter into the CMS data system, SHIPTalk.org.
Outreach and Community Presentations
A Public/Media Activity form must be used by all Regional Directors and speakers to capture information on all outreach events in the region. The activity forms should be entered into SHIPTalk as they occur.
Instructions and sample forms are in the SHIP NPR Training Manual.
Annual Work Plans are required from all SHINE Regional Directors. The objectives outlined within the SHINE grant will be the basis of the work plan. The State SHINE Director will provide this information to the Regional Directors upon receipt of the CMS grant announcement. The Annual Work Plan will be due in early February to coincide with the submission of the annual continuation application to CMS. An end-of-theyear report is included in the submission.
Mid-Year Reports are required from all SHINE Regional Directors. This report should outline the progress made to date on the Annual Work Plan objectives. The Mid-Year Report is Due September 25th of each year.
The Resource Report provides a counselor profile and is required from all SHINE Regional Directors. The report form can be found on SHIPTalk/NPR/Resource Report. This form should be downloaded. Regional Directors should complete the Local/Field sites column and send to State SHINE Director. DO NOT SUBMIT THIS REPORT TO SHIPTALK. This report will due May1 of each year.
Miscellaneous
Other reports may be requested from time to time, principally on the issues and concerns of consumers, training needs for new sites or counselor replacement, and other types of operational reports.
Performance Measurement Requirements and Standards for SHINE Contractors
SHINE contractor(s) will be evaluated on their accomplishments in meeting the objectives of the SHINE Program. The performance information gathered regarding a contractor may be used in the future evaluations of said contractor.
Performance Measures: CMS has instituted standard Performance Measures for all SHIPS. Annually CMS evaluates the performance and effectiveness of the SHIPs through these performance measurements as reflected in data entered into the national SHIPTalk data base. These are noted in the RFR. The state at one time had additional requirements on performance measures but these are no longer in place. However, the state SHINE Program reserves the right to add performance measurements as needed to satisfy state expectations. Appendix 51 and 51a are no longer in effect.
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PROHIBITION AGAINST PROVIDING PRIVATE INSURANCE APPLICATIONS INCLUDING HMO, MEDIGAP AND LONG TERM CARE