S2 E4 - Assessment

Katie White [: 00:00:11

Welcome to Pretend I Know Nothing About. I'm Katie White, your host, administrator of COAAA. On today's episode, we are learning about the assessment team from Tim Duggan and Anya Moore-Ridley. Our assessment team is made up of a number of talented individuals that ensure that those in the community meet level of care and Medicaid requirements in order to receive their home and community based services in their home or on assisted living. Part of our assessment team are PASSPORT assessors, assisted living waiver assessors, and MyCare assessors for the Aetna and Molina teams. Let's get into it. Welcome, Tim and On, to the podcast. So excited to have you both on today to talk about all things assessment.

Katie White [: 00:00:56

I'd like to kick us off with Tim. Can you share your name and your role here?

Timothy Duggan [: 00:01:02

Yeah. Thank you. My name is Timothy Duggan, or Tim Duggan. And, my role here is I'm clinical manager of the assessment and enrollment team. The assessment is has 2 elements. It has the Passport Assisted Living waiver side, and then it also has the MyCare team as well.

Katie White [: 00:01:19

Okay. And about how big are both of those teams?

Timothy Duggan [: 00:01:22

The MyCare team, we have about 35 on the, the entire team. The MyCare team consists of 10, and then obviously assisted Living and, passport would make up the rest.

Katie White [: 00:01:33

Okay. Great. Well, welcome. Hey.

Anya Ridley-Moore [: 00:01:36

How about you, Anya? Yeah. So well, On. Hey. So I am primarily just an assessor for PASSPORT. Okay. But, you know, we do other type of assessments too, and we'll probably get into that later. So yeah. Great.

Katie White [: 00:01:52

And so one of the other things that I think is fun is just to give, a little background on what you did before here, or if this is your 1st job. And so just tell us a little bit about your path, Tim.

Timothy Duggan [: 00:02:04

My path? Area enjoyable, blessed path. I, so I've had many decent experiences. I don't know how far back I can go because I'm a little bit on the, older side, but I'll join, when I moved to Ohio, I was connected immediately to social services, and prior to that, I worked within churches and worked with people. So I've always been interested in helping people. And then with the transition here, found the opportunity in social work and, saw that it is well, scratch the itch of that I have, I guess, Somewhere in my heart, just to help people to advocate, to support, and come beside. For the 1st part of my journey in social work, it was working with youth And, helping on a clinical level in the community, enjoyed it, had some great opportunities, found some opportunities to move up into the leadership there. And then I took a short stint away from social work. Had an enjoyable opportunity, but it did not scratch the right edge.

Timothy Duggan [: 00:03:08

So I eventually worked myself back here. And in 2014, I found myself at CO Triple A.

Katie White [: 00:03:15

Great.

Timothy Duggan [: 00:03:15

It was right on the, I guess it was the dawn of my care, so I was right at the front. The world was moving pretty fast at the agency, but I was fairly ignorant, so I didn't know what. I just kept saying yes whenever they asked me to do something. And, lo and behold, I said yes to the right things and was able to move into a supervisor role on the my Area team, which I stayed there For most of my tenure here at COAAA until just under a year ago, I moved over to the, position that I am now as the clinical manager.

Katie White [: 00:03:50

So great. So you've had a great career here. You came in in 2014, which is a year that a lot of people it's kinda like a Before and after my Area, depending on who you talk to around here. So glad that you came on and that you've worked your way up. So thank you so much.

Timothy Duggan [: 00:04:04

Thank you.

Katie White [: 00:04:05

Anya, how about you?

Anya Ridley-Moore [: 00:04:07

Let's see. So I'm not considered a baby social worker anymore, But I'm also not considered a tenured social worker anymore, so I'm right in the middle, now. So I actually started off in business school first, and then I changed my major after I went to a conference. Now, I went to a historically black university in Florida, and I was in one of my classes. And they said, hey, guys. Do you guys wanna go to New Orleans? I said, yeah. Sure. But what I didn't know I'm just a young college student.

Anya Ridley-Moore [: 00:04:47

I didn't know that I was gonna meet Social workers who are all about environmental justice and climate change, and that's how I changed my major to social work. And then I really got I fell in love with older adults. And so most of my experiences with older adults, I had time working in activities departments at assisted livings, I was with AmeriCorps with The Villages, and And then I got to see of triple a. And a little a little bit of those, social work Years, I was in mental health and substance abuse too, so I was on individual and group therapist. I I didn't like that part of social work. I was good at it, But I didn't like it. I said I need to go back to older adults. And, so then that's how I found my way back, back to older adults of coming Aging to see O Triple A and being a part of the assessment department, and I will be a assessor for 2 years in a few weeks.

Katie White [: 00:05:47

That's great. So were you with the local village network as an area of Corvista? I didn't know that. Which village?

Anya Ridley-Moore [: 00:05:52

Villa on the Hill. So I was on the hilltop area.

Katie White [: 00:05:54

Oh my gosh. Okay. So then Did we cross paths when you were there, or was I already

Anya Ridley-Moore [: 00:06:00

on the Village Network? I think you still were in the Village Network. Okay. And that's when Christine Happel was still with CRC. Yes. Yeah. I was in I think I was Vill on the Hill's first vista Okay. That they had. And I don't I don't really know what's happened since But it's yeah.

Katie White [: 00:06:16

That's great. All roads lead to c o triple a at some point, I think. Much. Especially if you have a love for older adults. Yeah. You really can't avoid this place in in a great way, if you're looking out for for older adults and people with disabilities. So great. This On of my favorite parts of every podcast because I feel like I learn things about people that I never knew.

Katie White [: 00:06:35

So we are going to start with Just kind of an overview of the assessment and enrollment department. So, Tim, I'm gonna pose that question to you.

Timothy Duggan [: 00:06:46

Just an overview. We we probably can be seen as the first face seen within the Agency. As the assessors, they they go out to determine the level of care, to see if they qualify for the passport assisted living waiver, and additionally, the MyCare, waiver through, because of the level of care. Now it The consumers enter the agency through, the screening team, but that's usually over the phone just getting background information to determine first steps. And then so then we go out and we meet the consumers in the home, try to determine, again, if they if they qualify based upon their activities of daily living, Get to know them, give a, a fresh face to the Agency, and also to provide resources if there's some additional supports needed that way. So we we really are the 1st face that they get to see. We do approximately, 60 assessments. We're assigned about 60 assessments a week, some of which come to fruition, Some of which do not.

Timothy Duggan [: 00:07:56

We just don't aren't unable to meet with the consumers. But that's about how many assignments we get on average every single week On the passport assisted living waiver side. On the MiCare side, they they muscle out a lot more Assessments, but they they're not necessarily the 1st phase for, the services since the my care entities have already seen them. So they're just out there doing the immediate assessment to determine level of care. So they do approximately a 170

Katie White [: 00:08:25

Oh, wow.

Timothy Duggan [: 00:08:26

Assessments a week. They have to do approximately 4 a day is our goal, and, we're we're we're pretty close. We're we're not quite hitting home runs yet, but we're getting pretty close with that one. So I give kudos to the supes in that in that domain.

Katie White [: 00:08:40

So that's a lot of people. Yeah. Yeah. So tell us, that's a lot of people that are coming in each week. Tell us how they get to us. How does somebody get referred To have an assessment at COAAA?

Timothy Duggan [: 00:08:52

Yeah. Great question. The they they come through different resources. ODA and ODM, provides resources I mean, referrals that that make it to us. Okay. The, MyCare team, often gets the referrals. If they're already on MyCare, but they're not on waiver, then they may come to us straight from the the plan itself.

Katie White [: 00:09:12

Okay.

Timothy Duggan [: 00:09:13

So we make it some that way as well. So these are the there's just multiple ways that they do make it to us, and the screening department does a wonderful job before they get to us to sort of ferret out, which which one of the 3 branches they'll fall into as far as the assessment team is concerned.

Katie White [: 00:09:29

Okay. And then 1 final question for you, and then we're gonna go to Anya. But Can you explain what the level of care means and kind of what they're looking for, and what qualifies you or disqualifies you?

Timothy Duggan [: 00:09:41

Yeah. Absolutely. And, I probably could do the for to Anya as well to this since she actually lives it, and breathes it. But the level of care, determines if they meet nursing facility level of care. And in order to do that, there's Few requirements, but a large part, leans back on their activities of daily living. Do they need additional support, hands on White activities of daily living. And some examples of activities of daily living are things like, bathing, feeding, also, transfers. So these Area just some of the examples, of different activities of daily living.

Timothy Duggan [: 00:10:24

There's there's some additional, elements that fall behind that to determine if they actually, qualify as well, but we're really out there COAAA the activities of daily living.

Katie White [: 00:10:34

Okay.

Timothy Duggan [: 00:10:35

And the next step from there is, in order to be qualified for waiver, Then they would also have to meet the, the the financial side of it as well, which is we can educate them on, but that is Determined, externally by jobs and family services. We just can help educate them a little bit on what to expect in that process.

Katie White [: 00:10:57

Okay. And the whole meaning behind the word waiver is instead of going into a nursing facility, if someone still meets that level of Area and financial need. The waiver is that they can receive those services in their home instead. Yep. Okay. Okay.

Timothy Duggan [: 00:11:14

That's correct.

Katie White [: 00:11:15

So now we know what we're looking for, if you will. Anye, walk us through when you get, an assessment scheduled, How do you call? You know? Where are you driving? What does it look like when you arrive? Just kinda talk us through the entire assessment process, if you will.

Anya Ridley-Moore [: 00:11:30

Yeah. So we so like Tim was saying about I don't know. You said 60 assignments a week. So those are split. You know? Of course, I couldn't get 60 assignments in 1 week, but they're split. So you could maybe have 1 to 4 assignments on a daily basis. And so you'll see your name on the list. You put them on however you organize your assignments.

Anya Ridley-Moore [: 00:11:55

I So you give them a call. So either it is the consumer themselves or it's usually a family member that you get things set up with. And the first thing is, do you have any questions about passport? That is the first question. Because a lot of the times, We are getting the referrals from multiple sources in the community. Sometimes they don't understand level of care criteria. They don't understand the Medicaid criteria. And so that's the first question to see what is their gauge of what they're actually applying for. And then if everything checks out, we get them scheduled.

Anya Ridley-Moore [: 00:12:37

And so I used to cover Three counties. So Franklin, Delaware, and Union. One of the newer assessors, thank god, she helped me out. She's covering Delaware now. So now I'm just Franklin and Union. Okay. We don't get that much from Union. Maybe I go out to Marysville, that type of Union County area Katie once a month, if that.

Anya Ridley-Moore [: 00:13:01

But then it's just primarily Franklin. So you want to confirm their address on the phone because sometimes they move. Sometime I don't it could be a lot of things. So you wanna make sure you're going to the right Address. You go out there, knock on the door, ring the doorbell. You make sure you bring your chair. Okay. Everyone has their c o triple a chair on case management or assessment.

Anya Ridley-Moore [: 00:13:25

And why is that? You never know. You never know if there's sitting room. You never know if they're gonna be in a hospital bed. That is one of the main things is you don't want to have the consumers move into a room. You need to Really meet them where they are in their house. Okay. But, also, we're going into unknown environment. So it could be pest.

Anya Ridley-Moore [: 00:13:49

You know? Roaches, bed bugs. Sometimes there could be mice. You really don't know. So you wanna bring in your own equipment. I hang my bag on my chair, and we just go through the assessment. And like Tim was saying, The primary focus is on the ADL. So we always say, like, the big three is bathing, dressing, and toileting. They have to usually, to get on our program, they have to meet at least 2 of those.

Katie White [: 00:14:21

That, like, they need assistance with at least 2? Yeah. Okay.

Anya Ridley-Moore [: 00:14:24

Hands on assistance with at least 2 of those, and that's how we know it's a nursing facility level of care. Is do you need is there some physical conditions or even cognitive, conditions like Alzheimer's or dementia White they're just to a point where they don't even know how, you know, to wash their bodies anymore, how to put on the shirt the right way, or, you know, things like that. And so we really look into those those details of the ADLs. And then if they meet criteria, we sign the enrollment paperwork. We do the documentation afterwards. And then, for passport, we pass it on to our enrollment team, and they help us out with that. Assisted living in my care is a little different with that enrollment process. But, yeah, that's usually what it looks like.

Katie White [: 00:15:11

Such, I, like, feel like I'm right there with you on one of your assessment visits. So 1 question I have you is regarding, actually assessing the need for assistance. Are you just asking that? Are you asking them to Show you.

Anya Ridley-Moore [: 00:15:26

Yeah. So I always like, back when I was in activities at assisted livings, I did the sittersize Okay. Activities. Yeah. And so I actually do that in my assessments too. Okay. And I asked for their range of motion. And so I'm like, are you able to put your hands above your head? Are you able to give yourself a hug? Are you able to touch your toes? If They can do that.

Anya Ridley-Moore [: 00:15:49

They usually are able to wash themself using a shower chair. They're able to put on their shoes and put on their jackets okay by themselves. And this one's a little bit more personal. But if they're able to touch their toes, that usually means that they're able to wipe their behind too when using the toilet. So that's usually White I ask them. And then sometimes I ask them to walk me to their bathroom, and they can show me how they transfer into their tub or their walk in shower too. But that's usually the gist. People are sometimes very straightforward if they need assistance with their ADLs or not.

Anya Ridley-Moore [: 00:16:26

Sometimes you kinda have to, like, pry it out of them and be a little bit more detailed with the questions or with the task that you're asking them. So, yeah, that's pretty much.

Katie White [: 00:16:38

That's a really interesting approach, and I love that you're bringing in the sitter size experience from being an activities assistant. When you were trained on doing assessments or when you train others, is that pretty common, the way that the questions are being phrased and that sort of thing?

Anya Ridley-Moore [: 00:16:52

Okay. Yeah. So, when I was being trained, I was actually trained by nurses for the most part, And they do it a little differently. They know how to ask more of the medical questions to see a nursing facility level of care rather than a social worker.

Katie White [: 00:17:10

Okay.

Anya Ridley-Moore [: 00:17:11

They could just look at a medication bottle and be like, yep. We can enroll them. Or, you know, or if someone's just on 1 medication, like an inhaler, Just on inhaler. Then they're like, no. You don't meet criteria. Here Area some other resources. But from a social worker's perspective, we really have to dig more into what we're observing and not so much the medical conditions. And that's that's usually How I teach the newer assessors, like, ask them to walk you, you know, walk you to their bathroom or ask them to show their range of motion, or Area they able to walk across the room okay with their rollator, walker, or cane? Because that's still considered independent if they're Aging, DME.

Anya Ridley-Moore [: 00:17:54

So, like, their walker or Katie. And so that wouldn't be counted as hands on. So, yeah, I I think You just kinda have to be a little detail oriented when it comes to the ADLs with them. So, I mean, it really just depends on the week. And that's one of the challenges is because we receive so many referrals from so many different sources. It could be a neighbor calling in. It could be ODM, and they're just looking that this is a older adult that applied for Medicaid, and they'll just send it to us. A lot of people don't meet our criteria, to be honest with you.

Anya Ridley-Moore [: 00:18:32

And most of the time, it's because of Medicaid criteria. It's usually assets that are involved where they don't meet the financial eligibility. And then a level of care comes into play where they're Still independent with all of their ADLs, but they need help with their laundry. But that, you know, that doesn't count for passport. That's not a nursing facility level of care. So then we usually try to get them connected with senior options. I always say that, like, if you're not with a waiver program or passport, Please get with your levy program. Okay.

Anya Ridley-Moore [: 00:19:06

So that's usually what happens. Okay.

Katie White [: 00:19:08

Great. And so senior options is Franklin County, which makes sense. Right. You're in Franklin County. Yeah. Okay. Got it. So, Tim, Anya mentioned, nurses as well.

Katie White [: 00:19:17

So your team is made up of nurses and social workers. Is that right? Any other disciplines?

Timothy Duggan [: 00:19:21

Yeah. That, As far as the assessors go, it is gonna be a licensed individual on nurses or social workers. We do have some additional support people that, do not, need licenses, but may have individual expertise. For example, our Medicaid specialists. They They are the magic behind the scenes, so often, and and are able to take a look at the systems and just sort of navigate the the the macro systems to help us get people enrolled.

Anya Ridley-Moore [: 00:19:49

Okay.

Timothy Duggan [: 00:19:50

We have the enrollment team as well, which they are the ones who help, after the assessment is completed, Assure that we get everything necessary, the doctor's letters and things like that. So they help out from, from an in office perspective of just sort of following up with calls and doing a little bit of the nonclinical side of it.

Katie White [: 00:20:11

Okay. So Anya comes back with a completed assessment, it goes to the enrollment team. And you mentioned a doctor's letter. What else are some of those requirements? And does that include Medicaid as well? Making sure that they qualify? Okay.

Timothy Duggan [: 00:20:25

That is yeah. That's absolutely part of it. And this this is, on the The passport side, the assisted living waiver has a little bit more of a different type of transition.

Katie White [: 00:20:35

Okay.

Timothy Duggan [: 00:20:35

On the my Area, since they already have Area managers at the different, COAAA, they they manage that part.

Katie White [: 00:20:42

Okay.

Timothy Duggan [: 00:20:43

But on the passport side after the assessment, the enrollment team, holds on to it. Helps White, identifying, potential services White needed. Waiting on the doctor's letter. It's used to be a piece that we're trying to Trying to figure out the best way and most efficient way to get, and then also waiting on, jobs and family services to assure that the financial elements are in Place.

Katie White [: 00:21:07

Okay. So then the enrollment team includes individuals getting the doctor's letter and different forms, getting all of that information then to our Medicaid specialists who are processing that through the, county job and family services to see if they're qualified for Medicaid. Is that right?

Timothy Duggan [: 00:21:24

They'll it's not a a simple stream where it goes from 1 to the other. The the, Medicaid specialist on the, enrollment team are on union Aging to accomplish the tasks. So they'll they'll feed back and forth information at the same time, And a little bit depends on what comes first. Either the JFS gets approved, and now we're waiting I mean, the financial part gets approved, And now we're waiting on the doctor's letter, or we get the doctor's letter, and now we're trying to push JFS to move the financials through. So they're both in, in Sharing the same timeline.

Katie White [: 00:22:00

Okay. And it's really kind of a complicated not kind of. It's a complicated web of some doctor's offices on you to fax Aging. Did they get the fax? Did they not? Is our fax machine on analog and theirs is on digital? And that might not work, and they so there's all these Different pieces and parts and variables that go into just 1 person's potential enrollment into Passport, Which I believe is why the enrollment team was created Katie only a year and a half, 2 years ago. Right? Just to really be able to specialize and kinda streamline some of that?

Timothy Duggan [: 00:22:31

That that yes. That's absolutely correct. The enrollment team is is a new entity, and they're, it's, been functioning for about a year. Okay. Just actually, I believe no. About a year, actually. Wow. And So they're trying to get their their legs underneath them.

Timothy Duggan [: 00:22:49

We are trying to White up. We we lost a few, then we got them back. And right now, they're actually plugging along at a really good clip.

Katie White [: 00:22:56

Great.

Timothy Duggan [: 00:22:56

But they're they're really their intent is to free up the assessors to focus on the level of Area, and then the, behind the scenes, on, following up with doctors and all that stuff. They they try to take off of the assessors, and just sort of see them through to the finish line. Okay. Sorta like a relay race,

Anya Ridley-Moore [: 00:23:14

I guess.

Katie White [: 00:23:14

Like a relay race. Yeah. Except it's, like, with obstacles or something. Like, it's like, like, course relay race.

Timothy Duggan [: 00:23:21

Hurdles. Yes. There's it's a relay hurdle race.

Anya Ridley-Moore [: 00:23:23

Yeah. The enrollment team made all the difference. So I was here before the enrollment team, and that was A lot.

Katie White [: 00:23:31

Yeah. Yeah. Yeah.

Anya Ridley-Moore [: 00:23:33

You you you just basically just had to You did everything that the enrollment team did now along with your assessments.

Katie White [: 00:23:41

Oh, wow.

Anya Ridley-Moore [: 00:23:42

And, so that was Amazing. Okay.

Katie White [: 00:23:46

So you would have been the person trying to get the doctor's order and trying to wow. Okay. Yeah. Yes. Now I can see really why that must be so helpful. Yeah. Especially to be able to just really specialize in one of the 2 areas, either the assessment or the enrollment piece and not being constantly pulled in all these different directions.

Anya Ridley-Moore [: 00:24:03

Yeah. There was still 2 individuals that, on moved to a different department. I think the other on actually went to, like, American Red Cross or something. But it was 2 individuals before the enrollment team White they found the services for the consumer, but us as assessors, we we still send the doctor's letter, but we didn't have to we don't have keep up with them anymore. As soon as we send them, the enrollment team just helps us out with that.

Katie White [: 00:24:28

Okay.

Anya Ridley-Moore [: 00:24:29

So they're really great. And, Also, with the Medicaid approval and the monthly contacts, the assessors were doing that. We had to reach back out to the families like, hey. Did you send in your mother's Social Security award letter? Like, did you do these things? And now the enrollment team is doing that, so it's just been wonderful.

Katie White [: 00:24:49

I can't imagine how everyone was doing it before the enrollment team, just knowing how much you're out in the community, but then all of those things need to be done here. And if you miss a call or a fax or Okay. Yeah. Okay. Well, what a brilliant idea that those that put together the enrollment team had. And lucky for us, we've got great members on there. Yeah. I, walk that hallway by their office quite a bit, and I just hear them on the phones all day.

Katie White [: 00:25:10

And they're just so kind and so patient and yeah. It's a good group. So I always like to, hear a little bit about someone's typical day or week. So, Anya, do you wanna start? What's your typical day or a typical week like for you.

Anya Ridley-Moore [: 00:25:26

So I do my assessments Monday through Thursday. Friday is usually my documentation day. You usually with a passport, our assessments are a bit more comprehensive. We have to gather a lot more information. Same thing with assisted living. So you're usually doing 2 a day. Some assessors do 3 in one day. I cannot.

Anya Ridley-Moore [: 00:25:51

I can't do that. But they give themself, either 2 documentation days or on and a half documentation days. So, I think that's the really great part of assessment. You really have a lot of autonomy with your schedule and, you know, hybrid work model and things like that. And you you schedule your own assessments. And so White that, I try to schedule my assessments in the morning, and then I'm traveling throughout My afternoon. So between 10 AM and 1 PM, I'm out in the community, and that's Monday through Thursday. And then after 1, I have a strong boundary with myself.

Anya Ridley-Moore [: 00:26:33

I I'm not on the phone unless it's something very important or it's like a consumer's family that I haven't been in contact with and trying to get them scheduled after, you know, 2 or 3 times. But that that's my documentation time, and that's how I kinda stay on top of my work. And then Fridays are primarily when I'm reaching out to pending consumers with assisted living or I'm getting through a lot more people to schedule for the Aging weeks, things like that. And that that's typically what it looks like. You're traveling between 10 AM to 1 PM, Monday through Thursday. You're you know? The morning hours are pretty much either you're scheduling people or you're getting ready for your day. Okay. And then at the end of the day, you're working on your documentation.

Anya Ridley-Moore [: 00:27:23

So, putting in your case notes, sending those doctor's letters, Sending the Medicaid applications to, the Medicaid specialist that we have, and that's pretty much what it looks like for the most part.

Katie White [: 00:27:37

And is documentation done on paper or in a computer system?

Anya Ridley-Moore [: 00:27:40

So all in our PIMS system. So computer system. Yeah. Just not paper.

Katie White [: 00:27:44

Okay. So you're you're taking notes throughout because at this point, you probably got it pretty well memorized, and then you go home and you document it in the computer.

Anya Ridley-Moore [: 00:27:52

Yeah. So at the assessment too, you're documenting on the PIM. So you can download your consumers' charts while you're out in the community. Okay. And, and so you wanna get as much information into PIMS while you're in the consumer's home. So then by the time that you're Back at home or back in the office, you're kinda just cleaning things up

Katie White [: 00:28:13

Okay.

Anya Ridley-Moore [: 00:28:13

And just finalizing your case notes and sending in the rest of the documentation. Okay.

Katie White [: 00:28:18

Because it is so comprehensive, you on get as much done when you're in the home. Okay. Yeah. Got it. And, Tim, how about you? What's your typical day or week like?

Timothy Duggan [: 00:28:29

Typical day or week. It's, I'm still learning, so I need to be candid about that. Emails and meetings, I think, is a large chunk of my my, onboarding piece. But I would say a huge part of my Tasks is really seeing the, information that's being fed into the stream and into the Agency. A large lot of, Policy changes and a lot of rule changes with ODA and ODM, and just trying to dissect and understand impact, on the on the program and also even downstream from there. That was a a learning curve for me as I was Starting to wrap my brain of how this impacts the assessment team and but recognize that since I'm in the rules, I need to also think how it impacts further downstream to care management and things like that, and and I'll pass along when I can. Now, obviously, they manage themselves more than competently, so so it's not a huge issue. But But I just didn't see the world that that big at that when I first came on board.

Timothy Duggan [: 00:29:32

So I would so outside of that, then it becomes an issue of just assessing and helping out the team, trying to build the culture that, that I think is appropriate for us as on Agency, so I spend a lot of energy on the floor Mhmm. Walking around, talking to people, which is challenging with the assessor since I I, Send them out into the world all the time, but

Anya Ridley-Moore [: 00:29:55

You you see you see us once a month.

Timothy Duggan [: 00:29:58

I do.

Anya Ridley-Moore [: 00:29:58

Pretty much. I do.

Katie White [: 00:29:59

You're out and about that much.

Anya Ridley-Moore [: 00:30:00

Yeah. Yeah.

Katie White [: 00:30:01

Yeah. Yeah.

Timothy Duggan [: 00:30:02

They are. They're out and about. And when they when they do come in, it's to gather gather paperwork to check off something or drop something off, and it's really an in and out. Okay. So I get to catch them on meeting days.

Katie White [: 00:30:14

That's on interesting point around keeping up with the Ever changing, it seems, policies and procedures of ODM or ODA and how you're sort of taking in all of that information, communicating it out as something might change so that when you're on the community, Anje, you know whatever it might be. But then the other side of the house of our case management, sometimes that can be affected too. So really working on that Cross department communication to make sure everyone is lockstep with all of these changes as they come out. Yeah. Yeah. That is a different view. It's like one of those things you know kinda operates in the background. And then when you're in charge of it, you're like, oh my.

Katie White [: 00:30:52

This is this is quite a bit of information.

Timothy Duggan [: 00:30:55

There there was I went to I was sent as the delegate to a pretty significant Get meeting and managed to pass along the information only to 1 group, and then a email came out about a month later on a policy change. And it was, like, anybody know about this? I'm like, yes. I did.

Katie White [: 00:31:11

I think I did.

Timothy Duggan [: 00:31:12

I just chose to keep it to myself. So so a little bit of a learning curve. And they're obviously, the programs it's a beautiful agency, and they've been more than gracious on allowing me to make those those mistakes as we go.

Katie White [: 00:31:24

I can echo that because I too am making all kinds of mistakes like that. There should I mean, there really is so much to take in all the time, so I feel you. I've when I was my 1st couple months here, I kept saying, like, am I in charge of that too? Am I supposed to read these as well? We got 7 notices on Tuesday. Do I need to know everything? And it's like, yeah. Yeah. You do. Now luckily, we have a lot of cross training and backup. But

Timothy Duggan [: 00:31:49

Yeah. Mhmm.

Katie White [: 00:31:50

Yeah. It's a lot, so I I feel you. Okay. One of my favorite things also is to know or have you guys share, like, one of your favorite stories or a success story. So take a second and think about that, but, would love to hear from both of you about one of your kinda favorite Stories.

Anya Ridley-Moore [: 00:32:08

When you're when you travel a lot in assessment, you're just thinking like, how can I help the next person, or how can it look Successful for them, like, making sure that their needs are met? Because like I said earlier, a lot of people don't meet our criteria for passport, and so you still wanna meet their needs in some type of way.

Katie White [: 00:32:26

Okay. Katie it's not that there's 1 episode or 1 story that necessarily sticks out because your job is about Continued success every time you're meeting with someone. Yeah.

Anya Ridley-Moore [: 00:32:38

And so I think that's what I was gonna say. Most of Most of this job so we do long term care consultations too in passport assessment.

Katie White [: 00:32:49

What do those look like?

Anya Ridley-Moore [: 00:32:50

And so, basically, I always say that, in assessment, you have to be a walking the source of all, like, Long term care services. Like, you have to know everything about anything to answer these family's questions. Mhmm. And it's just us. It's just You and the family. So sometimes you can be sitting there with, like, 5 family members, and they're all just like a round table, and they're just asking you questions. And, and most of our assessments are kinda designed to be a consultation in some way. Okay.

Anya Ridley-Moore [: 00:33:25

You want to know, 1, we're doing level of care. So are they getting assistance with their ADOs, or are they still independent? And then, you know, A lot of people don't think it's a big deal, but it's a big deal if a older dog can't take out their trash. You know? It is. And so we go through Agency triple a resource guide together and just go over resources with them. And I think that's my success because I I do it probably every other day if someone doesn't meet criteria, Area we're just going through the resource guide.

Timothy Duggan [: 00:33:55

Mhmm.

Anya Ridley-Moore [: 00:33:55

And that's what I do for their assessment of just, you know, here Area some resources that can help you. And they just feel, I don't know the correct word, seen on a way. Or For sure. Yeah. You know, they're like, oh, I never knew this existed. Now I was like, well, here you go. It's right here. Here's their number.

Anya Ridley-Moore [: 00:34:14

Give them a call. And, I think that's the successful part. And just It's really a type of advising that you do with these older adults who just wanna know what's available to them pretty much.

Katie White [: 00:34:27

Yeah. And I would say I mean, I think that's a great answer. It's not on success story that's that sticks out. It's because it's your continual dedication and work in the community to help individuals navigate this very It's complicated. Yeah. Complicated system. And so just, one point of clarification. So sometimes you're assigned to go out and do passport assessments, but other times you're assigned to go out and do long term care Consultations, which means, essentially, we know up front they're not qualifying or trying to qualify for passport or on care for that matter, but more along the lines of, I need to understand what's available in the community.

Katie White [: 00:35:03

Is that right?

Anya Ridley-Moore [: 00:35:04

Exactly that.

Katie White [: 00:35:04

Yeah. Okay. Great. Tim, how about you? And it can be from any of your, you know, experiences at c triple a. It doesn't have to be in your current role.

Timothy Duggan [: 00:35:12

Well, I I would like to, boast on on you then. Since she since she was Going around things, she may not be able to see how many times she actually crossed the finish line on some great accomplishments, but, from from our she has actually stepped up multiple times, asked her for extra tasks. Even the simple privilege of having her come in today, she was able to just coordinate her schedule, and she's always just been available for the team as a whole. So if I could Thank you. Boast on that for a second.

Katie White [: 00:35:44

Yes. I love that.

Timothy Duggan [: 00:35:46

For me, I would say my my biggest accomplishments is just the fact that I there's some great people around me. And I I I can take a little bit of credit for that, but, I think at best, I'm freeing them up to be the great people that they are at best. And, the enrollment team is is one of those places as far as the assessment side is concerned that I I feel very Proud about. I know that the wheels were put in place before I got there, but one of the pieces that was a little bit of a hiccup was the fact that it was The enrollment team and the assessment team, and they were siloed. And then you had the care management team, and that was siloed. And I've I've made, ardent efforts to try to remove some of those silos and allow us some overlap with each other.

Katie White [: 00:36:35

That's great.

Timothy Duggan [: 00:36:36

And, I'm starting to see the the the fruit of that. And that's that's pretty exciting to see that it's the assessors and the Roam team working together, identifying stress points and each one of them moving back and forth Aging to help out where those stress points are. Where I know there was some language when I first got there, it's that's not my job. That's the enrollment team's job. And just trying to break down those those barriers And those that that mindset. I don't know if it's a barrier. It's it was a mindset.

Katie White [: 00:37:05

Yeah. Yeah.

Timothy Duggan [: 00:37:06

And we're we're starting to see it, and it's fun that the enrolled team is now Fully staffed and they're starting to really be seen as a help. And talking to them even this morning, I was, like, see, now we're getting to the exciting part because now we're hitting the numbers.

Anya Ridley-Moore [: 00:37:21

Mhmm.

Timothy Duggan [: 00:37:21

And now we actually get to move to the creative part White we can say, what other value do I get to bring to the table to help? And, and it was fun to hear Here, a couple on the enrollment team just start to get excited about that because it's it's sort of what excites me.

Katie White [: 00:37:36

Yeah. I can tell. Your whole body just lights up, and you're smiling. And I think, when, you know, you were in the process of interviewing for this part of what you're known for is really that leadership and pulling a team together and getting everyone goal oriented. The tricky part when you come into a new role is it's hard to both learn and lead at the same time. Right? And so that takes a minute. And when your your, like, foundation to who you are is being a leader, but you know you can't quite get there yet because you have a lot to learn,

Timothy Duggan [: 00:38:05

Yeah.

Katie White [: 00:38:05

That takes some time. So, I love that you're seeing it all kinda congeal and feeling like you're, you know, settling into it. So that's great.

Timothy Duggan [: 00:38:14

It it is exciting. I thank you for the for those gracious words. I mean, truly, there there was the onboarding side, and, I I I do wanna tip my hat to, to Linda.

Anya Ridley-Moore [: 00:38:27

Of course. Absolutely.

Timothy Duggan [: 00:38:29

She's been a a a joy and

Katie White [: 00:38:32

She's a pillar of the

Timothy Duggan [: 00:38:33

agency. Goodness. Oh my goodness. And I attempted for it's funny. My attitude is to help other people build a team, But in my mind, I approached Linda for too long with the concept of let me take things off of her plate and help her White I really just needed to soak up the knowledge because of how much onboarding there is, how much new information, and she really just I mean, she just has it. I mean, it's just in her mind. I mean, it's It's in her hair. I mean, she just she understands policy and

Katie White [: 00:39:02

She does.

Timothy Duggan [: 00:39:03

All that.

Katie White [: 00:39:03

Yeah.

Timothy Duggan [: 00:39:04

So, So that is a little bit of a regret actually, if I could say that is, instead of soaking in the information from her, I tried to take it from her and learn it when I think I could have done a better job, at that point.

Katie White [: 00:39:18

Well and it's a really difficult position too. I mean, again, you're talking about someone with 35 years of Experience and expertise on trying to come in and, I I know I keep drawing parallels between us, but I think it's it's a It's a similar nuance of, like, wanting to be, helpful first, and it's hard to be like, well, I don't know anything, actually. So I just need to, like, learn first and then eventually be helpful. But, yeah. And I think so many people in the agency are like that too. You know? We're a lot of empaths and natural born leaders and people that are dedicated to the community. And so we naturally all wanna be helping whether it's consumers or each other or teammates. Yeah.

Katie White [: 00:39:57

We've got some good folks here.

Anya Ridley-Moore [: 00:39:58

Yeah. So we're all gonna cry in a couple months with Linda. We're all gonna cry.

Katie White [: 00:40:03

I know. 35 years.

Anya Ridley-Moore [: 00:40:04

Yeah. And I'd I want to, appreciate Tim really quickly because enrollment team I always felt that enrollment team should have been a part of team meetings, and it didn't happen till Tim actually is like, this makes a lot more sense. And, I mean, because I I talk with them often. Kayla was an assessor before. She be before the enrollment team. And Elise White all of her knowledge and all of her tips and tricks. And and I think it was very important. Like, guys because I talk with them probably the most mostly because Kayla was an assessor before.

Anya Ridley-Moore [: 00:40:44

And, and I I mean, I go visit Elise's This plant desk often when I am in the office. And so it was really important. Like, they were doing the work, but they weren't able to sit in the meetings to voice, you know, some of the things that they were dealing with. And so that that was very helpful for, both teams to actually combine when it came to it.

Katie White [: 00:41:07

Yeah. That streamlining of communication and working together and team building and, we're a huge agency. Right? Like, 385 People are something, I think, as of this week. And so it is it's easy to let things kinda get carried away and on their own, and we're all so focused. But I love more and more now that teams are realizing, okay. Wait. We have to slow down. We have to come together to your point earlier, Tim.

Katie White [: 00:41:31

Like, once we can get the systems and processes down, then we can innovate, then we can think White else, then we can be creative. Yeah. So okay. As we wrap things up, any final thoughts Or things that you want listeners to know about, the assessment process or the assessment team.

Timothy Duggan [: 00:41:50

The the the thing that I would on say, and I think this actually applies agency White, and it's probably one of the things that has helped me manage is I I have an ability Natural to just see see the strengths that exist around us. And it's not just the hiccups on the system that I get stuck on. And it is absolutely astounding, the amount of work we do within the community. The fact that, I mean, we have so many consumers that we have in our Area, and we we get so easily caught up by that Phone call or by that overload of documentation or that consumer that took 3 hours on what should have been a 15 minute visit, And we get caught up on the things that don't fit, where what really does fit is the fact that 95% of the consumers are Happy and grateful for the role that we get to contribute, for the assessment team gets to contribute. And They get to live in dignity with their choices intact, and we got to play a part in, Protecting that.

Katie White [: 00:42:56

Yes. I

Timothy Duggan [: 00:42:57

think if if anything, it's just recognize we do great work.

Katie White [: 00:43:00

Yeah.

Timothy Duggan [: 00:43:01

Under not always easy circumstances With yeah. I mean, there's a lot of reasons we could add to that. Yeah. That's the on. Anything.

Katie White [: 00:43:09

Yeah. The economy of scale around what we all do and how It's easy to lose sight when you're having a bad day, but if you pull back and think about, on average, 650 assessments a week, at any given time, case Aging over 12,000 individuals across the region, fielding 4,000 calls a month. Right? Like, the enormity of what we do is so huge. Yeah. That's a good reframe around yes. Maybe the 5% are outliers and challenging, and we're having frustrating days. But For the for the most part, we're we're the foundation in the community for these services.

Timothy Duggan [: 00:43:44

Yes.

Anya Ridley-Moore [: 00:43:45

Yeah. I like that when he said not focusing on the hiccups. Like we said, our referral system is complicated to say the least. Anyone can call in to see what services are available for older adults in the community. And I think us on our assessment team, that includes my care, we we get stuck on the hiccups until we actually talk to the consumer, and then they say, oh, I never knew existed. Mhmm. And then it makes us happy. So so, you know, I I think it's that tug in a pull with that.

Anya Ridley-Moore [: 00:44:17

On is We get stuck on the hiccups, but then we're like, oh, this is why I became a nurse. This is why I became a social worker. And, I I think that's Just wonderful.

Katie White [: 00:44:27

Yeah. And I think it's easy to get stuck on the hiccups when we all wanna make sure we're doing a really good job. And so when doing a good job is difficult or Impossible sometimes. That would be, that would be a challenge. But, yeah, we kind of persevere and get through it, and then hopefully rely on all of their team members as we get closer and closer to Push through those those hard times. Thank you both so much for being here. I learned so much as always. Appreciate it.

Timothy Duggan [: 00:44:53

Thank you very much.

Anya Ridley-Moore [: 00:44:54

Thank you. Wonderful.

Katie White [: 00:44:59

I hope now you know something about the assessment team.