Embed Size (px)
Citation preview
Nursing Facility Transition and Diversion
Module 1:Overview of Transition and Diversion in the Long Term
Care (LTC) System
Introductions
Who are you?
Why are you here and what is your experience with transition?
Please feel free to ask questions at any time
Handouts #1 and #2
Overview of Module #1
Myths and Truths in Long Term Care Nursing Facility Transition Work Characteristics of Successful Advocates CILs and Waiver Agents Landmark Legislation and Lawsuits Continued Efforts in Systems Change Transition Story #1
Myths and Truths (Handout #3)
1. Long term care can only be provided in a nursing facility.
2. People with disabilities and the elderly who have support needs are best served in nursing facilities for their own safety as nursing facilities provide 24 hour hands-on care.
3. A felony background or poor credit history history can prevent successful transition.
Myths and Truths
4. With proper support, anyone can live successfully in a community-based setting
5. Community based care is often more cost effective than nursing facility care
6. People who have guardians cannot live on their own in the community
Myths and Truths
7. Many people are lonely after transitioning back to the community.
8. Housing is often the biggest obstacle in the transition planning process.
9. Nursing facility staff are generally opposed to transition efforts.
Myths and Truths
10. In order to be successful, people who are transitioning must direct the process and play a key role in identifying and signing up for needed supports.
Nursing Facility Transition (NFT) Work
Exciting, challenging work
Addresses issues of Social Justice 14% of nursing facility residents are under age 65 Sometimes complex care needs Potential to have or maintain families and careers Most seniors prefer their own home
Advocacy Role
Nursing Facility Transition (NFT) Work
Steps in the process:
Outreach/Finding People to Transition Initial Interview and Informed Choice
Nursing Facility Transition (NFT) Work
Steps in the process continued
Working AgreementPlanning the TransitionTransitionFollow-up
Diversion
Steps in the process:
Identify referral sources Identify people at risk of permanent nursing
facility placement Intervene to prevent placement orFollow the person to the nursing facility and
plan transition
Diversion
“Home is a lot better than where I was. When I got home, I thought, ‘God, I hope I make it. I hope we can make it together.’ It was scary for me to leave, because I didn’t know if I could manage, but we are in good shape…for the shape we’re in! Without (my family’s) help, though, I would not be here today.”
Mrs. A., home after 183 days in the hospital
and 212 days in the nursing facility
Essential Characteristics of Advocates
Patience
Persistence or Tenacity
Passion
Essential Characteristics of Advocates
Listening Skills
Flexibility
Creativity
Organizational Skills, Reliability
Essential Resources for Transition
Centers for Independent Living (CILs)
Waiver AgentsArea Agencies on Aging Independent Waiver Agents
Landmark Legislation and Lawsuits
Disability Rights Movement
Began in 1970’sModeled after civil rights/women’s rights
movements Improved quality of life for people with
disabilitiesAccessibility and safety
Landmark Legislation and Lawsuits
Americans with Disabilities Act
Title II—State & Local Governments
Obligation to provide programs, services, and activities in the “most integrated setting.”
Landmark Legislation and Lawsuits
Olmstead versus L.C. & E.W.
Supreme Court Decision
Two women with mental disabilities
Moved back to community
Landmark Legislation and Lawsuits
Eager versus Engler/Granholm Michigan’s “Olmstead” lawsuit On behalf of nursing facility residents & people who
wanted to stay in the community with supports Settlement stipulated
Admission to MIChoice Waiver Training on LTC Uniform Eligibility Criteria Waiting lists for MIChoice Waiver Establishment of Medicaid Long Term Care Task Force
Landmark Legislation and Lawsuits
Medicaid Long-Term Care Task Force
Nine recommendations
Person Centered Planning Money Follows the Person Single Point of Entry Services and Supports Prevention Activities Consumer Participation LTC Workforce Quality Management System Financing Structures
Continued Efforts in Systems Change
Implement Task Force recommendations
Promote LegislationStatewide Efforts: (800) 760 4600 ext. 21 or
visit http://www.copower.org National Efforts: MiCASSA (Medicaid
Community Attendant Services and Supports Act) http://ww.freeourpeople.org
A Real Life Transition Story: Tenacious
Charlie
Background
In his late 60’s Became transition client
in December 2000 Has cerebral palsy (CP) Lived most of life in state
institutions Early attempt to live on
his own failed
Housing
Needed a barrier free, subsidized apartment
Long waiting lists for good housing
Multiple apartment applications
Several months to locate apartment
Very limited funding available
Accessibility 3 heavy steel doors to
enter building Could not unlock front
door Could not reach the
entrance buzzer No wheelchair accessible
shower Management was slow to
resolve these issues
Care Requirements
Needed Medicaid Waiver Services
Required help with all of his ADL needs
In 2000, Waiver slots very limited
Coordination of Housing and Waiver services
Financial
Very limited income Could not physically
manage his own checking account or bills
No family or long standing friends to assist
Needed representative payee
Other Challenges
In 2004, went back to nursing facility
Happy Endings
New apartment New opportunity thru NFTI
grant Transition fund purchases
Bathing system Automatic door opener
Charlie’s achievements On his own for 5 years Spoke at LTC public
hearings Active in the local CIL
For more information
Real Choice Systems Change Grants:http://www.communitylivingta.info/
ADA, Olmstead, MiCassa, etc:http://www.accessiblesociety.org/index.shtml
Medicaid LTC Task Force:http://www.healthteam.edu/imc/ltc/default.htm
Nursing Facility Transition Initiative Data & Stories: http://nfti.prosynergy.org or email: [email protected]
Resources
Centers for Independent Living Listingswww.macil.net
Waiver Agent Listingswww.miseniors.net
