Q0500: Return to Community

For Admission, Quarterly, and Annual Assessments.

Item Rationale

The goal of follow-up action is to initiate and maintain collaboration between the NH and the LCA to support the resident’s expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. The underlying intention of the return to the community item is to ensure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive setting appropriate for their needs. CMS has found that in many cases individuals requiring long term services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. LCAs are experts in available home and community-based service (HCBS) and can provide both the resident and the facility with valuable information.

Health-related Quality of Life

• Returning home or to a non-institutional setting can be beneficial to the residents’ healthand quality of life.

• This item identifies the resident’s desire to speak with someone about returning to community living. Based on the Americans with Disabilities Act and the 1999 U.S. Supreme Court decision in Olmstead v. L.C., residents needing long-term care services have a civil right to receive services in the least restrictive and most integrated setting.

• Item Q0500B requires that the resident be asked the question directly and formalizes the opportunity for the resident to be informed of and consider their options to return to community living. This ensures that the resident’s desire to learn about the possibility of returning to the community will be honored and appropriate follow-up measures will be taken.

• The goal is to obtain the informed choice and preferences expressed by the resident and to provide information about available community supports and services.

Planning for Care

• Many NH residents may be able to return to the community if they are provided appropriate assistance to facilitate care in a non-institutional setting.

Steps for Assessment: Interview Instructions

1. At the initial Admission assessment and in subsequent follow-up assessments (as applicable), make the resident comfortable by assuring them that this is a routine question that is asked of all residents.

2. Ask the resident if they would like to speak with someone about the possibility of returning to live and receive services in the community. Inform the resident that answering yes to this item signals the resident’s request for more information and will initiate a contact by someone with more information about supports available for living in the community. A successful transition will depend on the resident’s preferences and choices and the services, settings, and sometimes family supports that are available. In many cases individuals requiring long term care services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. Answering yes does not commit the resident to leaving the NH at a specific time; nor does it ensure that the resident will be able to move back to the community. Answering no is also not a permanent commitment. Also inform the resident that they can change their decision (i.e., whether or not they want to speak with someone) at any time.

3. Explain that this item is meant to provide the opportunity for the resident to get information and explore the possibility of different settings for receiving ongoing care. This step will help the resident clarify their discharge goals and identify important information for the LCA or, in some instances may indicate that the resident does not want to be referred to the LCA at this time. Also explain that the resident can change their mind at any time.

4. If the resident is unable to communicate their preference either verbally or nonverbally, the information can then be obtained from family or a significant other, as designated by the individual. If family or significant others are not available, a guardian or legally authorized representative, if one exists, can provide the information.

5. Ask the resident if they want information about different kinds of supports that may be available to support community living. Responding “yes” will be a way for the individual—and their family, significant other, or guardian or legally authorized representative—to obtain additional information about services and supports that would be available to support community living. It is simply a request for information, not a request for discharge.

Coding Instructions for Q0500B, Ask the resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond): “Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?”

A response code of 1, Yes, for this item indicates a desire to learn about home and community based services, it is not a request for discharge.

• Code 0, No: if the resident (or family or significant other, or guardian or legally authorized representative) states that they do not want to talk to someone about the possibility of returning to live and receive services in the community.

• Code 1, Yes: if the resident (or family or significant other, or guardian or legally authorized representative) states that they do want to talk to someone about the possibility of returning to live and receive services in the community.

• Code 9, Unknown or uncertain: if the resident cannot understand or respond and the family or significant other is not available to respond on the resident’s behalf and a guardian or legally authorized representative is not available or has not been appointed by the court.

Coding Instructions for Q0500C, Indicate information source for Q0500B

• Code 1, Resident: if the resident is the source for completing this item.

• Code 2, Family: if a family member is the source for completing this item because the resident is unable to respond.

• Code 3, Significant other: if a significant other of the resident is the source for completing this item because the resident is unable to respond.

• Code 4, Legal guardian: if a legal guardian of the resident is the source for completing this item because the resident is unable to respond.

• Code 5, Other legally authorized representative: if a legally authorized representative of the resident is the source for completing this item because the resident is unable to respond.

• Code 9, None of the above: if the resident cannot respond and the family, significant other, guardian, or legally authorized representative does not exist or cannot be contacted or is unable to respond (Q0310A = 9).

Coding Tips

• A “yes” response to item Q0500B will trigger follow-up care planning and contact with the facility’s designated LCA.

• Follow-up by the LCA is expected in a “reasonable” amount of time. Each state has its own policy for follow-up. It is important to know your state’s policy. The level and type of response needed by an individual is determined on a resident-by-resident basis. Some States may determine that the LCAs can make an initial telephone contact to identify the resident’s needs and/or set up the face-to-face visit/appointment. However, it is expected that most residents will have a face-to-face visit. In some States, an initial meeting is set up with the resident, facility staff, and LCA together to talk with the resident about their needs and community care options.

• Some residents will have a very clear expectation and some may change their expectations over time. Residents may also be unsure or unaware of the opportunities available to them for community living with needed services and supports.

• The SNF/NH should not assume that the resident cannot transition out of the SNF/NH due to their level of care needs. The SNF/NH and the resident should talk with the LCA to see what options are available for living and receiving services in the community.

• Return to community questions may upset residents who cannot understand what the question means and result in them being agitated or saddened by being asked the question. If the resident’s documented level of cognitive impairment is such that the resident does not understand Q0500, a family member, significant other, guardian and/or legally appointed decision-maker for that individual should be asked the question.

Examples

1. Resident B is an 82-year-old individual with COPD. They were referred to the NH by their physician for end-of-life palliative care. They responded, “I’m afraid I can’t” to itemQ0500B. The assessor should ask follow-up questions to understand why Resident B is afraid and explain that obtaining more information may help overcome some of their fears. They should also be informed that someone from an LCA is available to provide them with more information about receiving services and supports in the community. At the close of this discussion, Resident B says that they would like more information on community supports.

Coding: Q0500B would be coded 1, Yes.

Rationale: Coding Q0500B as yes should trigger a visit by the NH social worker to assess fears and concerns, as well as the designated LCA within a specified time frame established according to state policy.

2. Resident C is a 45-year-old individual with cerebral palsy and a learning disability who has been living in the facility for the past 20 years. They once lived in a group home but became ill and required hospitalization for pneumonia. After recovering in the hospital, Resident C was sent to the NH because they required regular chest physical therapy and were told that they could no longer live in their previous group home because their needs were more intensive. No one had asked them about returning to the community until now. When administered the MDS assessment, they responded yes to item Q0500B.

Coding: Q0500B would be coded 1, Yes.

Rationale: Resident C’s discussions with staff in the NH should be noted in their care plan, and care planning should be initiated to assess their preferences and needs for possible transition to the community. NH staff should contact the designated LCA according to established state guidelines, for them to initiate discussions with Resident C about options for returning to community living.

3. Resident D is a 65-year-old individual with a severe heart condition and interstitial pulmonary fibrosis. At the last Quarterly assessment, Resident D had been asked about returning to the community and their response was no. They also responded no to item Q0500B. The assessor should ask why they responded no. Depending upon this response, follow-up questions could include, “Is it that you think you cannot get the care you need in the community? Do you have a home to return to? Do you have any family or friends to assist you in any way?” Resident D responds no to the follow-up questions and does not want to offer any more information or talk about it any further.

Coding: Q0500B would be coded 0, No.

Rationale: During this assessment, they were asked about returning to the community and they responded no.