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Nursing Facility Transitions

DELAWARE

Identified Problems with the State's Long-Term Care System

• Lack of affordable and accessible housing.


• Insufficient transportation options to meet the needs of people with disabilities.


• Scarcity of resources for personal attendant services.


• Lack of consumer outreach regarding options for community living.

Perceived Strengths

• Long-standing relationships between Independent Resources Inc. (IRI), the state's only Independent Living Center (ILC), and state and private organizations that provide services for the elderly and adults with physical disabilities.


• IRI provides outreach and education, funded by a HUD grant, to increase awareness of the rights and responsibilities for people with disabilities under the Fair Housing Act.


• The state's recently passed Medicaid Community Attendant Supports and Services Act (MiCASSA) will direct up to $680,000 of state and federal money into attendant care.


• Delaware Area Rapid Transit has promised to replace old buses with lift-equipped buses as they are retired, and all buses in the capital city of Dover are lift-equipped. There is a statewide on-call bus service for people with disabilities, Delaware Area Specialized Transit (DAST), that will transport a person with 24–hours notice for only a few dollars each way.


• The state has ARC's model transition program to build on, which relocates people with mental retardation into smaller homes owned and operated by ARC.


• The state has a consumer-directed attendant care program administered by Easter Seals and funded by the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD).

Primary Focus of Grant Activities

• Develop and implement efficient transition plans.


• Increase consumer and caregiver knowledge about available housing options.


• Improve community-integrated services to enable more people to live in the community.

Goals, Objectives, and Activities

Overall Goal. Create and implement an enduring system of public and private support groups that will help transition people from nursing facilities into community living.

Goal. Conduct outreach to identify persons with disabilities residing in nursing facilities who wish to transition into the community.

Objectives/Activities

• Develop and distribute outreach materials regarding community living options to consumers, caregivers, nursing facilities, and public and private organizations.


• Schedule workshops on community housing options throughout the state for stakeholders, including nursing facility residents, their friends and family, and social workers.


• Survey nursing facility residents and their families to determine their interest in transitioning, and provide ongoing transition support once the consumer is relocated in the community.


• Meet with facilities staff, social workers and case managers to familiarize them with the transition program.

Goal. Coordinate with private partners to provide needed services and supplies for transitioning consumers.

Objectives/Activities

• Work with partners such as Lowe's Home Improvement and Home Depot to provide supplies for ramps, small platforms, or other home modifications as needed. At present, IRI maintains a storage facility in each of the three counties where we have collected donations of varies furniture and other household goods and items. These would be made available to whoever needed them. The supplies are not funded as a grant initiative.


• Work with the Division for the Visually Impaired in New Castle County to teach consumers to use computers.


• Educate consumers prior to transition through a series of workshops entitled "On My Own Workshops," and use mini-grant funding from the Delaware Developmental Disabilities Council to help transiting consumers with application fees, purchasing a telephone, acquiring appropriate ID, etc.

Key Activities and Products

• Compile a list of outreach recipients and update quarterly.


• Develop outreach materials for distribution twice a year and schedule workshops for stakeholders twice a year.


• Provide outreach and education to nursing home residents and their families, nursing facilities staff, social workers, and case managers.


• Provide peer counseling and independent living skills training to all transitioning consumers.


• Meet with DSAAPD and other partners quarterly to get feedback about grant activities and incorporate changes when needed.

Consumer Partners

• More than 51 percent of IRI Board of Directors are members with disabilities who were able to provide a consumer perspective to grant planning activities.


• The Nursing Home Transition Grant Oversight Committee (GOC) comprises a combination of members from all the grant private and public partners as well as consumers.

Consumer Partners and Consumer Involvement in Planning Activities

Consumers form the majority of the lead agency's board and staff and were involved from the concept stage onward.

Consumer Partners and Consumer Involvement in Implementation Activities

• The GOC will be established to monitor the project and ensure that the goals will be met on time. The committee will include nursing facility residents.


• Consumers on the GOC will be serving in an advisory capacity to the project, analyzing what actions had taken place, in addition to offering suggestions on what would work better. Current graduates of the program will be invited to become members of the GOC, in addition to acting as mentors to those currently enrolled in the workshop program. Consumers are not currently in the majority on the Committee.


• Feedback will be solicited from the outreach workshop participants to evaluate effectiveness and make changes to outreach programs as necessary.

Public Partners

• Division of Services for Aging and Adults with Physical Disabilities (DSAAPD).


• Division for the Visually Impaired.

Private Partners

• United Cerebral Palsy.


• Developmental Disabilities Council.


• ARC.


• Delaware Assistive Technology Initiative.


• Lowe's Home Improvement and Home Depot.

Public and Private Partnership Development/Involvement in the Planning Phase

Public Partners

The grant was developed in partnership with DSAAPD as they developed a companion Nursing Facility Transition Grant (the state program).

Private Partners

None were involved.

Public and Private Partnership Development/Involvement in Implementation

Public Partners

• On all activities, the grant will work in close collaboration with DSAAPD, the lead grantee on the state program NFT Grant.


• The Division for the Visually Impaired will expand a program of computer training for blind or visually impaired individuals to include people leaving nursing facilities.

Private Partners

• United Cerebral Palsy (UCP) will assist with outreach to a large base of consumers, facilities and caregivers.


• Developmental Disabilities Council will assist with outreach to a large base of consumers, facilities and caregivers.


• ARC, which has an existing transition program of its own, will provide transition training for IRI.


• Delaware Assistive Technology Initiative will provide advice, training and hands-on experience to inform IRI about technology that can make work or home more accessible.


• Lowe's Home Improvement stores and Home Depot will provide supplies and home furnishings.

Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities

• IRI hopes to capitalize on Delaware's new Medicaid Community Attendant Supports and Services Act, which will earmark up to $680,000 state and federal funds to increase the number of personal care attendants in the state.


• IRI is in partnership with the State Council for Persons with Disabilities, the State Developmental Disabilities Commission, and Housing Opportunities of Northern Delaware to present workshops throughout the state that address consumers housing rights under the federal Fair Housing Act. This partnership is funded through a grant from the U.S. Department of Housing and Urban Development and it will be used as a model of a successful private/public partnership for the IRI-DSAAPD partnership for this grant.

Oversight/Advisory Committee

• The Nursing Home Transition Grant Oversight Committee comprises a combination of members from all the grant private and public partners as well consumers.


• The oversight committee will not only act as an advisor to the project (what is working, what is not working, who else needs to be involved, etc.), but also help in the overall evaluation of the project and in setting outcome standards.

Formative Learning and Evaluation Activities

• Quarterly meetings with the lead state agency and other grant partners to solicit feedback about grant activities and make changes to the program as needed.


• Feedback will be solicited from the consumer outreach meetings on the effectiveness of grant activities and to identify changes that may be necessary.

Evidence of Enduring Change/Sustainability

• Successful transition to community living for 30 individuals.


• Successful increase in IRI staffing where IRI will absorb the additional staff positions in its overall budget. Ideally, we will be able to acquire additional monies through funding sources that will be explored.


• Outreach programs and materials will be developed in-house and be continually reproduced.

Geographic Focus

Statewide.