SSD/IWISH Consent Form

2528-XXXX; expiring 12-31-2020

Integrated Wellness in Supportive Housing (IWISH)

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: The public reporting burden for this information collection is estimated to be 10 minutes. This burden estimate includes time for reading this information and signing the consent statement. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal Investigative Services, Attn: OMB Number (3206-0246), 1900 E Street NW, Washington, DC 20415-7900.

TITLE OF STUDY: Integrated Wellness in Supportive Housing (IWISH)

INVESTIGATOR: Lisa Alecxih, MPA

(703) 269-5542

SPONSOR: United States Department of Housing and Urban Development

INTRODUCTION

The United States Department of Housing and Urban Development (HUD) funded Integrated Wellness in Supportive Housing (IWISH) to study the impact of trained wellness staff hired to support your health and supportive service needs.

IWISH aims to support you in better managing your health. Several outcomes interest HUD, including:

• decreasing inappropriate use of emergency rooms and hospitals ;

• delaying potential admission to nursing homes; and

• supporting you in maintaining independence in your home for a longer period of time.

We are asking you to participate in IWISH since you live in a property that has been selected to be a part of this initiative.

It is important that you read and understand the following explanation of the proposed IWISH activities. This form describes the purpose, activities, benefits, and risks of IWISH.

A member of the IWISH staff will read through this consent form with you and discuss the information included. When you feel you understand IWISH, you will then be asked if you agree to participate. If you agree, you will be asked to sign this consent form. Once you sign the form, we will give you a signed and dated copy to keep.

You do not have to consent to participate right away. You may take this form and show it to family, friends, and other supportive individuals. You may want to discuss your participation in IWISH with them to help decide if you want to participate.

Please note, you can withdraw your participation and consent for IWISH at any time. Participation in IWISH and receipt of supportive services are completely voluntary. Your ability to continue to live in your home does not depend on participation in IWISH. No negative action will be taken based on participation or non-participation in IWISH.

If you decide to withdraw your consent to participate from IWISH you will no longer be eligible for certain enhanced and new services provided under IWISH. However, you will continue to receive the same level of service coordination that you have always received.

GENERAL INFORMATION ABOUT THE DEMONSTRATION

Forty HUD properties were selected to begin IWISH, including (name of housing property). IWISH will last three years. As long as you are willing to consent to the program and you continue to live at this property, we will involve you in IWISH activities.

Once you agree to participate, I (insert name here) as the Resident Wellness Director and our Wellness Nurse (insert name here) will talk with you to get to know you and your potential health and social service needs. After this initial conversation, we will meet with you to complete a Resident Assessment. This assessment may take up to 80-minutes to complete, but will help us better understand your health preferences, including emergency contacts and provider details, as well as specific health conditions, and social services you already receive or may need. You don’t have to answer all the questions if you don’t want to, or if you are not comfortable.

We invite you to participate in IWISH activities, including wellness programming and health education events. We request that you meet with me and the Wellness Nurse regularly to inform us of your health and social conditions or concerns. We are also here to discuss any new needs that you experience. Please note, as a part of IWISH, we will provide wellness and services that support any transitions you may have from the hospital or a nursing home, but we will not provide any direct medical services.

Enrollment in IWISH is free. There is no cost for you to enroll or obtain services through IWISH. In exchange for your participation, you will receive coordination of your health and supportive services. You will also benefit from wellness and health prevention programs. These programs are designed to help you manage your health and make healthy life choices that can help you live at home longer. Should you choose to decline to participate, there are no anticipated risks.

All data collected through IWISH will be kept private to the extent allowed by law.

HUD seeks to understand whether IWISH is effective at meeting its primary goals of:

• supporting participants in better managing their health;

• decreasing unnecessary emergency room and hospital use;

• delaying potential admission to nursing homes; and

• supporting participants in maintaining independence in their homes.

To answer these questions, HUD has contracted with an independent evaluation contractor to evaluate the program. To support the evaluation, we will transfer to the evaluation contractor all the information we collect from you and about you over the course of the demonstration. The contractor will use the personal identifying information that you provide, such as your name, social security number, and insurance number, to match with Medicare and Medicaid data and with HUD administrative records.

At the conclusion of this project, findings may be published in a summary format. No information gathered can be used to identify you and will not be used in any publication or presentation.

Notice of Privacy Practices

As a participant in IWISH, medical or health status information about you may be used and disclosed, as you deem appropriate. At any time you may request access to information collected as part of your participation in IWISH.

Your Health Information Rights

You have the right to:

• Receive a copy and an explanation of this consent for participation in IWISH.

• Understand how we intend to use and share your information with others, as approved by you, or required by law.

• Look at and/or receive a copy of your records (subject to some restrictions).

• Request that your records be changed if you believe the information is incomplete or incorrect (subject to some restrictions).

• File a complaint if you believe your rights under this agreement have been violated.

• Revoke any authorization that you give for use and disclosure of your health information at any time.

B. Our Responsibilities

The [Insert housing name] as required by law, accepts the responsibility to maintain the privacy of any health information that you share with us and to provide to you this Notice of its privacy practices. We will follow the terms of this Notice. You will be promptly notified in writing if there are any major changes to any of the privacy practices stated in this Notice. You will also be notified if there is ever an unauthorized use or disclosure of your health information.

We will not use or share your health information without authorization, except as described in this Notice (See below).

C. Routine Uses and Disclosures

With your authorization, we will use and/or share your health information to:

• Develop your Individual Healthy Aging Plan (IHAP), and develop the Community Healthy Living Plan.

• Coordinate care and supports for you with community partners.

• Support transitions home for you from hospital and nursing home stays.

• Schedule or remind you about upcoming appointments.

• Let you know about services that may be of interest to you.

• Conduct operations, such as quality assurance, performance improvement, staff supervision, staff education, accreditation and compliance reviews, or business planning.

• Record your information in a cloud-based server, electronically.

D. Legally Required Disclosures

Whether or not we have your authorization, we may use and/or disclose protected health information when required by federal, state, or local law to:

• Report risks to public health.

• Prevent or lessen serious and imminent threats to health and safety.

• Report abuse, neglect or domestic violence.

• Respond to inquiries from law enforcement officials, medical review board, or health oversight agencies.

• Respond to subpoenas for a judicial and administrative proceeding.

• Respond to requests to government agencies responsible for national security.

• Provide information to coroners, medical examiners, or funeral directors.

• Assist employers with workers’ compensation claims.

E. Complaints

If you believe your privacy rights have been violated, you can file a complaint with Lisa Alecxih at (703) 269-5542 or [email protected].

PARTICIPANT’S STATEMENT:

I agree that I have been given a chance to ask questions about IWISH. These questions have been answered to my satisfaction. I may contact Lisa Alecxih at (703) 269-5542 if I have any more questions about taking part in IWISH.

My participation in IWISH is voluntary. I may quit IWISH at any time without harming my future medical care or losing any benefits to which I might be entitled. The investigator in charge of this study may decide at any time that I should no longer participate in this study.

If I have questions about my rights as a research subject, other concerns about the research, or I am unable to reach the investigator; I can contact:

New England Institutional Review Board

Telephone: 1-800-232-9570

By signing this form, I have not waived any of my legal rights.

I agree to participate in IWISH. I will be given a copy of this signed and dated form for my own records.

__________________________________ _________

Study Participant (signature) Date

__________________________________

Print Participant’s Name

__________________________________ ________

Person who explained this study (signature) Date

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