social worker and woman filling out forms

Discussing Return to Community Living: Best Practices for MDS Section Q

Originally presented on March 21, 2019

Suzanne de Beaumont, MPH

Project Director Open Doors Transition Center
New York Association on Independent Living

Robin Chiaravalle, LMSW
Director of Social Work
Warren Center Rehabilitation and Healthcare

Coordination, collaboration and knowledge of current supports and services are key to providing quality, cost effective health care. Federal requirements such as the Olmstead decision and 2016 guidance from the US Department of Health and Human Services emphasize the importance of ensuring that individuals living in institutions have the opportunity to learn about community resources available to support independent living. In New York State, the Open Doors program is the Local Contact Agency responsible for educating nursing home residents on their community-based options and facilitating transitions for residents wishing to return to their communities.

The Minimum Data Set (MDS), a mandated quarterly assessment administered to all nursing home residents, includes Section Q, which assesses the interest of residents in discussing options to return to community living. The requirements of Section Q are often misinterpreted, resulting in confusion about this part of the MDS, and missed opportunities for referral to the Local Contact Agency. This webcast will review the intent of Section Q and provide an in-depth discussion of the MDS Section Q questions to assist in referral to Open Doors. By sharing best practices in administering Section Q and making Local Contact Agency referrals, the information will help long-term care staff optimize patient outcomes and assist facilities in meeting their responsibility in meeting the Olmstead decision.

Note: Participants are encouraged to watch the recorded Public Health Live! webcast, “The Money Follows the Person Program: Facilitating Return to Community-based Settings,” which aired on February 16, 2017. 

Learning Outcome:
As a result of this activity, the learner will enhance or gain knowledge and ability to more effectively recognize the intent of the MDS Section Q, and administer best practices in completing Section Q.

Learning Objectives:
After watching the webcast, participants will be able to:

  • Identify the steps to take when an individual expresses interest in returning to community living from an institution;
  • Explain the proper administration of the MDS  Section Q interview with nursing home residents; and 
  • Describe when a referral to the Local Contact Agency is appropriate.

Target Audience
Nurses, social workers, and discharge planning staff, physicians, medical directors, care managers, and other health care professionals working in long-term care facilities and community-based organizations supporting independent living.

CE credits expired for this program on March 31, 2022. 

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