This 2006 Annual Report and the content henceforth serves as a historical reference on the development, implementation and operation of the Aging & Disability Resource Center serving Calumet, Outagamie and Waupaca Counties.

INTRODUCTION

A collaborative grant application for the development of an Aging & Disability Resource Center (ADRC) was submitted to the Wisconsin Department of Health and Family Services on January 14, 2005 by Calumet, Outagamie and WaupacaCounties. The tri-county consortium grant application was approved and publicly acknowledged by Wisconsin Department of Health and Family Services Secretary Helene Nelson on April 28, 2005. Through a Wisconsin Department of Health and Family Services planning grant, the ADRC contracted with a Project Coordinator January 2, 2006 through July 1, 2006 to oversee grant development and began consortium operation on July 3, 2006. APPENDIX A The ADRC is the first multi-county consortium in Wisconsin.

The consortium’s “answering the call” value provides services to: older adults; adults with developmental and/or physical disabilities; youth with disabilities transitioning into the adult long term support system; adults with mental health and/or substance abuse concerns; adults seeking current information, advice, assistance, resources, and long term support; family caregivers, professionals, and others interested in maintaining good health, independence and preventing or delaying the need for long term care; plus adults planning for future long term care needs.

“Answering the call” is treating each consumer as an individual. This value reflects the Wisconsin Department of Health and Family Services “RESPECT” philosophy. RESPECT is an acronym for Relations between consumers, care managers and providers; Empowerment to make choices; Services to meet consumer needs; Physical and mental health services to help consumers reach their best level of functioning; Enhancement of consumer reputations; Community and family participation; plus Tools for self determination. The ADRC accomplishes this philosophy through consumer easy access and seamless entry to: information and assistance/referral; long term care options counseling; benefits counseling; short term case management; eligibility determination for long term support benefits; plus prevention and early intervention programs.

Information and Assistance/Referral

ADRC staff provide information and assistance/referral to consumers, their families and advocates, professionals and the public about services, resources, and benefits in areas of:disability; long term care related services; living arrangements; physical health; behavioral health; adult protective services; employment and training for consumers with disabilities; transportation; supportive home care and maintenance; caregiver support; and nutrition, etc. Staff connect consumers with services and resources plus assist consumers in applying for government benefits such as disability income, FoodShare Wisconsin, Medicare, etc.

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The IRis comprehensive web based resources database is available to staff for reference. IRis is maintained by United Way Fox Cities and is a collaborative project between the following partners: Community Foundation of the Fox Cites, UnitedWayFoxCities, Calumet, Outagamie, Waupaca and WinnebagoCounties.

Information and assistance/referral includes:

  • Listening to the consumer
  • Assessing consumer needs
  • Assisting consumer to connect with needed service providers
  • Following-up with consumer or service provider to determine if needs were met

Staffprovide service in the following ways:

  • In personconsultation by appointment
  • Consultation to “walk-in” consumers
  • Home visits to homebound consumers upon need
  • Consumer contact via telephone, electronic mail, fax or written correspondence
  • Distribute branch resource directories, regional service provider brochures or other written information
  • Educate and assist consumers and the public to access branch websites for information

Assistance is provided to consumers who may not be able to follow through on their own with the information received. If assistance is not initially provided, another opportunity to assist consumers occurs when a follow-up contact is made to determine if consumer need was met.

The ADRC meets the state requirement for Alliance of Information and Referral Systems (AIRS) certification having certified staff at each branch.

Long Term Care Options Counseling

ADRC staff provide unbiased consultation and advice about options available to meet consumer long term care needs. Consultation includes what to consider when making long term care decisions. The consortium offers pre-admission consultation to all consumers with long term care needs entering nursing homes, adult family homes and assisted living facilities to provide objective information about the cost effective options available. Staff provide long term care options counseling as a continuum to the information and assistance/referral service.

Benefits Counseling

The ADRC ensures that consumers who are 18 years to 59 with physical and developmental disabilities have access to the Disability Benefit Specialist and consumers 60 years and older have access to the Elderly Benefit Specialist. Consumers receive accurate and current information regarding public and private benefits plus services such as disability income, Social Security, FoodShare Wisconsin, Medicare, vocational rehabilitation services, etc.

Both Disability Benefit Specialist and Elderly Benefit Specialist staff reside at each branch and adhere to the confidentiality standards set forth by program and county Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance standards.

Short Term Case Management

The ADRC offers assistance in identifying consumer needs and connects consumers to community resources. This includes assisting consumers in choosing a service provider, making service referrals for consumers and overseeing consumer services on a short term basis to insure needs are met.

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Services are intended to be of limited duration. To ensure that the ADRC does not become a long term case management provider, short term case management is limited to a period of sixty (60) calendar days from the date of initial contact. A thirty (30) day extension may be granted, if the consumer has not received necessary resources, additional consumer needs have been identified, there are significant changes in consumer circumstances since the beginning of service or obstacles are encountered beyond consumer control. When determined eligible for long term support benefits, consumers are referred to the county branch long term support unit for continuing services.

Consortium staff provide short term case management to assist youth with specialized education needs/disabilities and their families in preparing for and accessing services after high school graduation. Staff also complete protective placement studies as requested and petitions the courts for eligible consumers in need of a guardianship.

Eligibility Determination for Long Term Support Benefits

ADRC staff will assist consumers in determining their eligibility for long term support benefits by assessing consumer financial and functional needs in the following areas: income and asset declaration; activities of daily living (bathing, dressing, mobility, transfers, eating and toileting); instrumental activities of daily living (meal preparation, money and medication management, telephone, transportation and employment); health related tasks (skilled nursing); diagnosis; behavioral symptoms; and cognition. The long term care functional screen assessment tool provides information on risk factors, mental health and substance abuse plus where the consumer would like to live. The assessment determines consumer disability and nursing home level of care plus functional eligibility level for state long term support benefits.

Prevention and Early Intervention Programs

The ADRC promotes effective prevention efforts to keep consumers healthy and independent because it is the philosophyof the consortium to treat consumers holistically. The consortium strives to prevent or reduce hospital and institutional admissions by providing prevention and early intervention programs and activities that focus on reducing the risk of injury and disability.

Prevention and early intervention programs and activities include: providing the Elderly Nutrition Program meal services at each consortium branch; reviewing medications; offering caregiver support; nutrition education and counseling; home safety checks; appropriate fitness programs for older adults and consumers with disabilities, etc.Prevention and early intervention programs help consumers retain or improve functioning and delay or prevent the need for comprehensive long term support benefits. Through information and assistance/referral; long term care options counseling; short term case management; plus assessing consumer environmental risk factors in determining eligibility for state funded long term support, staff are able to identify and provide prevention education and early intervention programs to consumers in need.

The ADRC links consumers to public health providers, UW Extension services as well as to other public health focused entities that have health prevention, early intervention, disease management, etc. activities and programs. Every attempt is made to promote prevention and early intervention plus secure funding responding to consumer needs.

The consortium partners with existing private and public services such as hospitals, health care providers, assisted living facilities, nursing homes, funeral homes, community programs, etc. to uphold the “answering the call” value. Partnering eliminates duplication of services and provides the opportunity for service and program expansion to meet unmet and emerging consumer needs. The ADRC enables consumers to live at home with ready access to community resources promoting choice, quality of life and cost effectiveness through a single point of contact.

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ADRC GOVERNING STRUCTURE

The governing structure is under the direction of the Consortium Advisory Committee. CalumetCounty is the designated fiscal agent for the consortium.

The Consortium Advisory Committee was created having equal membership and representation from all three (3) counties. The power and duties of the Consortium Advisory Committee will be exercised and performed in conformity with the ordinances and resolutions of the tri-county consortium. The role of the Consortium Advisory Committee is to help develop the ADRC mission, structure, policies, procedures and operation. Composition of the Consortium Advisory Committee represents the ethnic, economic and geographic diversity of Calumet, Outagamie and WaupacaCounties. APPENDIX B - Consortium Advisory Committee Membership

The following ADRC staff positions and programs reside at each branch:

ADRC Supervisor Responsible for daily branch operations; insures compliance with all state and federal guidelines and requirements; insures quality assurance and smooth service delivery of the ADRC and aging related branch programs; provides outreach and public education; and supervises branch staff.

Elderly Benefit Specialist Provides benefit assessment and counseling services to consumers 60 years and older; represents consumers in denials of benefits; works in conjunction with CWAG Elder Law Center in formal appeals; provides education on benefits and related topics; provides information and assistance/referral; plus provides benefit options counseling. Each county branch employs an Elderly Benefit Specialist.

Disability Benefit Specialist Provides benefit assessment and counseling services to consumers 18 years to 59; represents consumers in benefit denials; works in conjunction with Disability Rights Wisconsin in formal appeals; provides education on benefits and related topics; provides information and assistance/referral; plus provides benefit options counseling. CalumetCounty, acting as the consortium fiscal agent, contracts with Valley Packaging, Inc. for the provision of Disability Benefit Specialist staff.

Information and Assistance Specialist Conducts initial consumer assessment. Determines if a consumer is in need of adult protective services and makes appropriate referrals. Completes long term care functional screen assessments to determine consumer eligibility for long term support benefits. Develops care plans to meet consumer needs. Provides unbiased options counseling to consumers and/or their families, information and assistance/referral services plus short term case management.

Youth with disabilities experience seamless entry into the adult long term care system through contact with an Information and Assistance Specialist. Calumet, Outagamie and Waupaca County Human Services departments have well established transition processes in place with local school districts for youth graduating from high school and requiring long term support benefits. Consumer referrals begin entry at any branch but are routed by the Information and Assistance Specialist to the county of residence if the consumer requires long term support funding or is in need of adult protective services.

The OutagamieCounty branch contracts with Lutheran Social Services of Wisconsin and Upper Michigan, Inc. through “Senior Connection” to provide branch information and assistance/referral plus short term case management.

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Older Americans Act Program Staff Provides Older Americans Act program coordination at each branch including: Transportation; Elderly Nutrition Program Congregate and Home Delivered meal services; Caregiver Support; plus other aging related programs serving consumers 60 years and older.

Prevention and Early Intervention Programs Consortium staff collaborate with public health departments, UW-Extension, health care providers and other community partners in the provision of evidence based prevention activities with the goal of preventing or slowing consumer need for state funded long term support.

APPENDIX C- Organizational Chart

CULTURAL COMPETENCE AND DIVERSITY

Access to services and the effectiveness of care is greatly affected by the degree to which the delivery system is “culturally competent” and free from cultural barriers. As a culturally competent consortium, policies, procedures and services are not discriminating and address the needs of consumers and their families with diverse values, beliefs, sexual orientation backgrounds that vary by race, ethnicity, religion, language and circumstances such as physical, mental and/or developmental disabilities that would otherwise be a barrier to obtaining services. The ADRC is comprised of staff and consumers from a variety of differing racial, ethnic and cultural identities.

ACCOMMODATIONS AND ACCESSIBILITY

The ADRC accommodates consumers with physical and/or functional limitations or language differences and has the ability to provide materials in alternate formats to accommodate non English speaking consumers with a physical disability. For consumers speaking languages other than English, contracts with local translation and TTY (text telephone) services are available.

Informational materials are written in consideration of consumer need. Information available at each consortium branch, may be mailed to consumers or may be accessed through the Internet. Consumers may access branch websites for specific branch service information.

Branches are located in county facilities that are accessible to consumers with mobility impairments and comply with the Americans with Disabilities Act (ADA) regulations. Staff will meet consumers in their home or other locations upon need.

COMMUNITY NEEDS ASSESSMENT

The ADRC is committed to community needs assessments plus promotes access, choice, quality of life and cost effectiveness for services to aging, disabled, mental health and substance abuse consumers with a philosophy of dignity, integrity, seamless entry and service follow through.

SHARED EFFICIENCIES AND ACCOMPLISHMENTS

Shared activities, services and grant applications greatly enhance the quality of experience and contact for consumers served throughout the tri-county consortium. Through collaboration and partnership, the following shared efficiencies and accomplishments were achieved in 2006:

Jointly received a Wisconsin Department of Health and Family Services planning grant to create and develop the tri-county consortium.

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Jointly contracted for a Project Coordinator to assist with consortium planning, development, service coordination and implementation.

Provided a no cost, single point of contact for consumers regardless of income.

Provided toll free telephone access to any consortium branch.

Collaboration with United Way Fox Cities providing one nationally advertised toll free 2-1-1 telephone referral entrance to consortium branch services. Calls coming into the 2-1-1 system are transferred to the designated branch during business hours. After hours, consortium calls are transferred to the Outagamie County Department of Health and Human Services - Crisis Unit.

Consortium shared consumer resources; staff services and training; outreach; marketing; needs assessments; state and federal reporting; health education; prevention promotion; plus grant opportunities.

Reduced and/or eliminated duplication of consortium costs and efforts.

Expanded resources available to consortium service area consumers through one (1) IRis web based community resources database.

Jointly received a Pathways to Independence state grant to purchase employment and assistive technology resources to reside at each branch.

Jointly received a Wisconsin Department of Health and Family Services two (2) year prevention grant to implement the “Spills and Pills” capacity-building, community outreach program to address falls prevention and medication management for improved quality of life. The “Spills and Pills” program began implementation on May 1, 2006.

Hosted an ADRC Open House on September 14, 2006 at each branch. During Open House promotional activities, staff and representatives greeted the public and shared information about consortium operation and services.

MARKETING

The ADRC utilized a variety of marketing and outreach activities to inform the public of options and services available. Marketing strategies covered four (4) areas of consumer access: community education; collaboration; communication and media.

In 2006, the consortium contracted with Willems Marketing who matched “dollar for dollar” to assist with ADRC marketing. Neighboring ADRCs were invited to join the consortium marketing effort that proved to be cost effective and successful.