Transition to Community
Institutional Care To Community – Based Living
Acentra Health will serve as the Local Contact Agency (LCA), responsible for providing interested Nursing Facility (NF) residents with options counseling for transitioning from a facility back to the community.
The LCA coordinates these face-to-face conversations with the person residing in the facility, the facility point of contact and as appropriate, family members or other supports after a referral has been made by a skilled nursing facility.
For more information on this change beginning November 6, 2023, please see MDS Section Q Referrals Process Change.
For Residents and Families
Being separated from a loved one after admission into a Skilled Nursing Facility can be challenging. In cases where it is
the ultimate desire of the individual, and their family, to return to community living, options counseling is available.
Partnering with nursing home facilities, Acentra will:
- Respond quickly, within 5 days, to the referral of interest for options counseling.
- Take a team approach to transition planning by working with the resident, nursing home staff, and those who support the individual (family or friends)
- Provide information and assisting with identifying community-based resources needed for a safe and successful transition
- Follow-up with the resident and staff, when necessary, regarding the progress leading up to the transition process.
Common Questions
A Counselor of the LCA will:
- Share information with the resident about community-based services that may be available to support living outside of the nursing home to facilitate decision making.
- Provide consultation to the resident and facility discharge team about community-based services.
- Collect information about the services and supports needed to enable the resident to transition, if they choose, to a less restrictive setting.
There are three ways you can make a referral to the LCA for Options Counseling:
1. Complete the ‘Options Referral Form’and fax it to 833.521.2627.
2. Complete the ‘Options Referral Form’and email it to NCLIFTSSLCA@kepro.com
3. Call the Acentra Customer Support line at 833-522-5429 and select ‘Option 6.' When making a referral via phone, nursing facilities will need to provide the following Resident Demographics:
- Name
- DOB
- Date of Admission
- Phone contact information
- Significant Other/Guardian/Legally Authorized Representative
- Pay Source
And the following facilities contact information:
- Name of staff contact
- Phone
- Name of facility
- Facility address
- County
- Money Follows the Person (MFP)Money Follows the Person (MFP) | NC Medicaid (ncdhhs.gov)
- Program of All-Inclusive Care for the Elderly (PACE) Program of All-Inclusive Care for the Elderly (PACE) | NC Medicaid (ncdhhs.gov)
- Community Alternatives Program for Disabled Adults (CAP/DA) https://medicaid.ncdhhs.gov/providers/programs-and-services/long-term-care/community-alternatives-program-disabled-adults-capda
- Area Agencies on Aginghttps://www.ncdhhs.gov/divisions/aging-and-adult-services/adult-day-services/area-agencies-aging
For Facilities and Stakeholders
Acentra is proud to operate at the states Local Contact Agency and work directly with nursing home
facilities to engage residents in their discharge and transition planning, and collaboratively work to arrange
all of the necessary community-based, long-term care supports and services.
How can a nursing facility submit a referral for
Options Counseling for a resident?
There are three ways you can make a referral to the LCA for Options Counseling:
1: Complete the ‘Options Referral Form’ and fax it to 833.521.2627
2: Complete the ‘Options Referral Form’ and email it to NCLIFTSSLCA@kepro.com
3: Call the Acentra Customer Support line at 833-522-5429 and select ‘Option 6’
When making a referral via phone, nursing facilities will need to provide the following Resident Demographics:
- Name, DOB, date of admission, phone number, and pay source
- Name of Family/Significant Other/Guardian/Legally Authorized Representative/ that assisted the resident in completing Section Q (MDS 3.0)
- Facility name and contact information: Staff contact, phone, email, and address
And the following facilities contact information:
- Name of staff contact
- Phone
- Name of facility
- Facility address
- City
- County
What can a facility expect once they make a referral for Options Counseling?
- Acentra will reach out to the facility and work with the resident to schedule the counseling session within 5 days from the date of referral.
- Acentra Assessor will conduct the counseling session within 10 days from the date of referral.
- The Assessor will call the facility within 24-48 hours prior to the scheduled counseling session and complete a ‘Pre-Assessment’ with the facility. The Assessor will need to gather information on:
- Where the resident wants to move to?
- What is their financial status?
- What are the ‘known’ challenges or barriers?
- This information will allow the Assessor to come prepared with a list of appropriate resources.
Once arrived at the facility, the Acentra Assessor will:
- Share information with the resident about community-based services that may be available to support living outside of the nursing home to facilitate decision making.
- Provide consultation to the resident and facility discharge team about community-based services.
- Collect information about the services and supports needed to enable the resident to transition, if they choose, to a less restrictive setting.
- Discuss required follow-up, if needed, as the resident progresses closer to the transition period.
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