Action Steps

County Agency Information

1) Contact DHS – We need to know when you plan to begin using the Long Term Care Functional Screen (LTC FS) and determine an implementation schedule for your agency.

□ Return this form to the Division of Disability and Elder Services.

□ DDES will provide you with the materials you need to proceed.

County:

Agency:

Contact:

Phone:

E-mail:

2) Designate a staff person to be the Screen Lead for your agency –This person should be someone who will become knowledgeable of the screen, be responsible for local screen quality assurance and will be the main point of contact for DDES staff.

□ Let DDES know who will be the screen lead.

□ DDES staff will coordinate all other activities through this person.

Name:

Address:

Phone:

E-mail:

Fax:

3) Complete required clinical training (WebCT Course) –To be a qualified screener, a person must meet the care manager requirements contained in Section 5.01 C of the Community Options Guidelines and must pass the WebCT course. Screens for persons with developmental disabilities must be conducted or reviewed by a person who is a qualified mental retardation specialist.

□ Each screener develops a log-in ID per instructions provided—this is for access to the web-based training.

□ Screener successfully completes WebCT.

□ Graduates receive certificate of completion from DHS and 12 social worker continuing education hours.

How many people do you anticipate becoming qualified screeners?

4) Attend Application Orientation/ Training – This session provides an overview of the LTC FS computer application and is an opportunity for hands-on experience. The screen lead and other selected lead staff will attend training and then assist colleagues. Training sessions will be scheduled around the state at locations with a computer classroom.

□ Identify lead staff to attend training (it is recommended that these individuals have some experience with computers).

□ Lead staff attend training at site selected based on your determined start date and geographic location.

□ Individuals return to county to train and assist other screeners.

□ Each county will have a temporary training ID to allow people to practice screening skills.

Indicate top two training choices:

February Waukesha _____

Madison _____

March Oshkosh _____

Rhinelander _____

April Waukesha _____

Eau Claire _____

May Rhinelander _____

Superior _____

June Oshkosh _____

Mosinee _____

For training after July 1, indicate preferred month & site _______________________

Lead staff to attend training (up to four):

1)

2)

3)

4)

5) Get security access – When the county agency is ready to begin using the LTC FS, each screener must apply for security access to use the LTC FS.

□ Each screener creates a user ID and password on the LTC FS website.

□ Each screener completes an "LTCIA Web Access Request" form. Supervisor and county security officer must sign form.

□ Fax form to DHS —access should be activated within 72 hours.

Supervisor Name(s):

Agency/County Security Officer Name:

6) Participate in on-going quality activities – Counties and the State have on-going responsibilities for quality use of the screen.

□ State provides clinical and systems technical assistance for counties.

□ County develops and implements quality plan to ensure accurate and consistent use of the LTC FS.

□ State monitors county use of screen for quality.

DDES staff will work with your Screen Lead to ensure follow-up and quality assurance.