Nursing Facility Transitions
Identified Problems with the State's Long-Term Care System
- Lack of accessible services and lack of community supports.
- Lack of coordination among agencies responsible for HCBS programs.
- Failure to maintain accurate information on waiting lists.
- Failure to expand home and community options for long-term care by applying for HCBS waivers.
- Lack of services that are culturally and linguistically appropriate.
- Lack of affordable, accessible housing.
- Lack of personal care assistants.
- Lack of accessible transportation.
- Lack of technology that could increase consumer self-reliance.
- Lack of consumer involvement in policy or decision-making related to long-term care.
- Lack of equitable and effective evaluation/assessment standards to assure quality and satisfaction as determined by the consumer.
- Lack of reliable, easily accessible and timely information and referral about options for long-term care.
- Inability to identify persons living in residential facilities who would choose to live in the community.
- Medi-Cal (California's Medicaid) is the primary payer for long-term care services and funds a wide array of home and community services, including personal care and chore services, in-home medical care, adult day health care, case management, and mental and behavioral health services.
- More individuals use Medi-Cal home and community services than use institutional services.
- Community Resources for Independence (CRI) has extensive experience providing services and support for individuals of all ages with all types of disability in areas of environmental (suburban, urban, rural) and cultural (Native American, Hispanic) diversity.
Primary Focus of Grant Activities
- Develop resources, quality services, and policy recommendations to facilitate transition.
- Improve access to services by developing a new transition model and conducting outreach and education.
- Develop a proposal for a statewide funding mechanism to implement the transitions model.
- Address barriers to successful transitions in local, state, and federal policy and regulations.
- Assure consumer direction, involvement, and participation at all levels of the project.
Goals, Objectives, and Activities
Overall Goal. Develop an enduring, replicable, statewide model for transitioning individuals from institutions, including resources, quality services, and policy recommendations.
Goal. Assist 10 to 12 persons with disabilities, currently in institutional settings, to transition to community living during each year of the grant project.
- Develop and facilitate with consumers an Independent Living Plan that will include accessible housing (if needed) and home and community services.
- Conduct outreach in nursing facilities to identify and receive referrals for consumers who wish to transition, and research the factors that led to their institutional placement.
- Provide direct advocacy on behalf of consumers and assist them in developing independent living skills, including self-advocacy, personal assistant management, budgeting, interacting with agencies, and social skills to facilitate their transition into the community.
- Match individuals who choose to transition to the community with appropriate Peer Support Mentor Team (PSMT)volunteers who will provide support and service coordination throughout the transition process and follow-up.
Goal. Address barriers to successful transitions, including affordable and accessible housing, expansion of home and community services options, and expansion of community social and relationship links.
- Conduct outreach to hospital social workers, discharge planners, nursing homes, family members, and others throughout the pilot area.
- Create partnerships with community housing and HCBS organizations to increase staff knowledge of housing and HCBS options, which staff can pass on to consumers when developing Independent Living Plans for individuals who are transitioning.
- Organize a Transitions Task Force (TTF) composed of consumers, service providers, advocates, and project staff to develop a systematic statewide outreach to increase community awareness of the nursing facility transition program.
- The TTF will develop informational materials for dissemination to target groups, including individuals residing in nursing facilities, or who are at risk of entering one, as well as their families or significant others who might influence decisions about long-term care.
Goal. Develop a volunteer PSMT to assist consumers to develop problem solving techniques, cultivate a network of support, and acquire the confidence needed to sustain the consumer's choice to live independently.
- Develop a PSMT consisting of approximately eight to ten volunteers representing individuals who have a disability or chronic illness, or who have successfully transitioned into community living, and who rely on long-term care services and supports.
- Implement an 8week peer support training program for the PSMT to include cross-disability/cross-cultural issues, listening and attending skills, depression and crisis intervention, independent living philosophy, substance abuse, oppression, and self-esteem.
- The PSMT will evaluate the effectiveness of current assessment procedures to identify individuals in the community who are "at risk" of placement in an institutional setting.
- The PSMT will provide one-on-one encouragement and counseling and serve as role models to help people making the transition to community living.
Goal. Develop and expand waiver options and personal care options to facilitate transition to community living.
- Study, recommend, and affect change through the Transitions Advocacy Group (TAG) and TTF to improve existing home and community services and consumer-directed care programs.
- Develop and recommend a statewide funding mechanism to support Independent Living Centers (ILCs) in their efforts to transition individuals into community living.
- Explore the use of Title VII B funding to pay for necessary items during the transition process, such as rental deposits, essential furniture purchases, and first groceries purchases.
- The TAG will lobby for the passage of the state-level Medicaid Community Attendant Services and Supports Act program, which will make home and community-based services an entitlement in the state's Medicaid program.
Goal. Address barriers to successful transitions in local, state and federal policy.
- Project staff, selected CRI Board members, and consumers will form a TAG to address issues of public policy and practices with regard to home and community services.
- The TAG will assess the extent to which community services are available and identify improvements that can be addressed and successfully altered.
- Working closely with the state's Medi-Cal agency, the TAG will explore the current level of HCBS Waiver usage, review intake and admissions processes for institutions with an emphasis on consumer choice, accessibility, and cultural appropriateness.
- The TAG will explore reimbursement issues, the availability of durable medical equipment, and address the lack of accessible and affordable housing with local housing authorities.
Goal. Assure consumer direction, involvement and participation at all levels of the Transitions Grant project.
- Incorporate consumers and advocates in the TAG to solicit their input.
- Create a PSMT comprising consumers who have successfully transitioned to community living, or who live in the community and have a disability or chronic illness, that will play an integral role in the transitioning process.
Key Activities and Products
- Develop a systematic statewide outreach and community awareness program through information materials, target groups, and other activities.
- Create a volunteer TTF composed of consumers, service providers, advocates, and project staff to implement outreach, education, and community awareness initiatives.
- Transition 10 to 12 individuals in the pilot area each year of the project, using a volunteer PSMT to develop and facilitate Independent Living Plans for successful transition to the community.
- Affect change in public policies, practices and procedures, with regard to home and community services, to assure individuals with a disability or chronic illness maximum choice and opportunity to live in a community setting.
- Consumers play a major role in all functions of CRI, both as employees and members of its Board of Directors.
- The TTF will be composed of consumers, service providers, advocates, and project staff to implement outreach, education, and community awareness initiatives.
- Project staff, selected CRI Board members, and consumers will form a TAG to address issues of public policy and practices.
- The PSMT will include consumers who have transitioned to community living, or who live in the community and have a disability or chronic illness.
Consumer Partners and Consumer Involvement in Planning Activities
Consumers comprise more than 51 percent of CRI's Board and therefore had major influence on grant planning activities.
Consumer Partners and Consumer Involvement in Implementation Activities
- Consumers will comprise the majority of the TAG, which will be the main entity advising on state policy changes for greater access to community living options. TAG will assess the extent to which community services are available and identify improvements that can be addressed and successfully altered.
- The project's TTF, consisting of a majority of consumers, will assist CRI staff in developing outreach materials.
- The PSMT will evaluate the effectiveness of current assessment procedures to identify individuals in the community who are "at risk" of placement in an institutional setting. The team will also provide one-on-one encouragement and counseling and serve as role models to help people making the transition to community living.
- Peer Support Mentors have also assisted with the development of our Transitions Program brochure, and periodically assist in sending cards and letters to keep us in touch with our transitions consumers.
- California Department of Rehabilitation.
- Local Housing Authorities (in particular, Sonoma County Community Development Commission).
- California Medi-Cal Agency.
Private Partners and Subcontractors
- Coalition of Californians for Olmstead.
- California State Independent Living Council.
- California Foundation for Independent Living Centers.
- San Diego Independent Living Center.
- Grass Valley Independent Living Center.
- Independent Living Resource Center San Francisco.
- Access Center of San Diego.
Public and Private Partnership Development/Involvement in the Planning Phase
None were involved.
The Grass Valley, San Francisco, and San Diego ILC's helped with making available information from their Olmstead Planning Workgroups. They brought forward questions and issues we needed to address in our grant writing stage.
Public and Private Partnership Development/Involvement in Implementation
- The State Department of Rehabilitation will act as a liaison between the project and other state departments and agencies to secure necessary cooperation for transitioning individuals. The department will commit staff and resources for technical assistance to ensure that training needs are met, and will assist in disseminating outreach information throughout the state. The department will also provide staff and resources for CRI to share this model nationwide at the annual NCIL conference.
- Sonoma County Community Development Commission (the county's local housing authority) has indicated willingness to annually set aside 12 housing vouchers for the Transitions Project.
- The California Medi-Cal Agency will help CRI explore the current level of HCBS use and will be involved in the review of intake and admission processes.
- The California Department of Rehabilitation will provide funding ideas for implementing the database project.
- CRI will contract with San Diego, San Francisco, and Grass Valley ILCs to provide training and technical assistance to address statewide issues, barriers, and opportunities.
- The Access Center of San Diego will provide technical assistance.
- CRI, along with the State Independent Living Council, will explore using Title VIII B dollars for "gap filling" uses during the transitioning process.
- The Coalition of Californians for Olmstead will assist CRI in working with the Governor's State Long-Term Care Council. The council is involved because the grantees participate in their counsel activities, and keep them informed of our progress. The council will be part of the list serve.
- California Foundation for Independent Living Centers will be involved at the level of working with legislation that is being introduced, or needing to be introduced, regarding the Olmstead State Plan and/or moneys for Transitioning Projects in the state.
Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities
CRI has resources and existing collaborations with various entities which will be utilized extensively throughout the project. These include CRI's Disability Law Clinic, its collaborative working relationships with the Sonoma County Human Services Department In-Home Supportive Services, the North Coast Rehabilitation Center, and the Sonoma County Council on Aging, its Housing Accessibility Modifications Program (HAM), its Deaf Services Program, its collaboration with the Sonoma County Task Force on the Homeless, its Housing Program, and its Peer Support Program.
An oversight and advisory committee will comprise past and present nursing facility residents, ILC advocates, Medi-Cal staff program liaisons, and California Department of Rehabilitation staff. This committee has not yet been developed, but when formed will develop its own oversight activities.
Formative Learning and Evaluation Activities
- Consumer surveys will use consumer satisfaction and quality of life measures and will provide data on living arrangements, use of long-term care services, changes in health, and functional status.
- Data from surveys, assessments, and forums will determine the extent of community and professional awareness of long-term care options.
- Conduct analysis of fiscal impact data of the Transitions Project on community, state, and federal resources.
- Analyze state agency resources utilized and expended.
- A final evaluation will be developed through a contract with the World Institute on Disability (WID) in Oakland, CA, and a report on their findings will be developed on the 3year impact the Transitions Project had on individuals with disabilities, the community and its resources, the actual transition process and public policy issues.
Evidence of Enduring Change/Sustainability
- Materials and processes developed for promoting community awareness: CRI will continue to use its Transitions Program outreach and information materials as part of its range of services for long-term care options. Getting people out of institutions and keeping them out is becoming a core service for ILC's, so developed materials will be shared with other ILC's for their use as they transition individuals.
- Community networks to provide information regarding the availability and variety of long-term care options: we hope that our Transitions Project will have enough positive outcomes that the state will be interested in funding transitions projects for ILC's in general.
- The Peer Support Mentoring Team: we foresee that the Transitions PSMT will continue as part of CRI's core services, including the general Peer Support Training Program.
- Development of appropriate assessment material and a standardized interview guide for consumers indicating a willingness to transition to community living, which will be available outside the pilot area after the grant.
Sonoma, Lake, Napa, and Mendocino counties.