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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.

Frequently Asked Questions

Q. What is LCA?

A. Acentra Health serves as the Local Contact Agency (LCA) responsible for providing community support options counseling to nursing home residents. The LCA coordinates face-to-face conversations with the resident and Nursing Home Staff to discuss options for transitioning to the community once a resident indicates interest in learning more about transitioning home during their assessment (MDS 3.0). The LCA will provide contact information for community-based services to facilitate transition to home. 

Q. What is MDS and MDS 3.0?

A. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS 3.0 is a tool in support of the Americans with Disabilities Act and the Olmstead ruling. It includes resident-centered planning and transition planning and provides an opportunity to further balance long term care services.  Section Q in MDS 3.0 is a part of the assessment tool that collects information about the resident's interest in discharge planning. The intent is to record the participation and expectations of the resident, family members or significant others and understand the resident’s overall goals.  

Q. What does the LCA do?

A.  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. 

Q. How do I make a referral to the LCA for Options Counseling?

A. 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 
  • Email 
  • Name of facility 
  • Facility address 
  • County 

Q. What is Options Counseling?

A. Options Counseling provides information and guidance to individuals seeking community support options which could enable them to transition out of a facility and return to their home or community living. 

Q. What can the resident family expect once a referral has been made for Options Counseling?

A. Acentra Health will reach out to the resident at the nursing facility and schedule the counseling session within 5 days from the date of referral. An Acentra Health Counselor will conduct the counseling session within 10-days from the date of referral. Once arrived at the facility, the Counselor will ask to connect with the transition coordinator/case manager for the resident. The Counselor will work with this contact to set up the interview, in a private space, with the resident and any family members who were requested to be in attendance. Once gathered, the Counselor will proceed with the options counseling interview utilizing active listening and a person-centered approach. Based on the responses, the Counselor will provide and review a list of resources to assist the resident in the transition back to community-based living. 

Q. What are examples of some of the Community Resources that will be provided during the Options Counseling?