Nursing Facility Transitions
Identified Problems with the State's Long-Term Care System
- Lack of a single, comprehensive assessment or survey indicating the number of institutionalized individuals who may meet the conditions for community services.
- Lack of specialized transition staff knowledgeable about community resources.
- Lack of education/outreach efforts to assist residents in making informed decisions.
- In many cases, nursing facility residents no longer own their own homes, have exhausted their financial resources and have become disconnected from family and friends.
- Delays between time of discharge from nursing home and start of community services.
- No "bed-hold" for sufficient time to let residents test movement back into the community.
- South Carolina's Medicaid waiver programs, which have been successful for over two decades in providing alternatives to nursing facility placements.
- Waiver programs build upon existing community and family resources, and serve to enhance the systems already in place.
- There is a common point of entry for institutional and community long-term care services.
- Initial assessment is the same for both institutional and community long-term care, and is automated, which ensures comprehensive data comparable across long-term care locations.
- South Carolina has recently implemented CareCalla telephone verification system to track and monitor many in-home waiver services.
Primary Focus of Grant Activities
- Develop mechanisms to identify consumers that would like to return to the community.
- Develop services and supports and community partnerships to support transitioning consumers.
- Develop Community Transition Nursing service to assist with medical transition issues.
Goals, Objectives, and Activities
Overall Goal. Develop the infrastructure and partnerships necessary to create viable options for nursing facility residents to return to the community.
Goal. Develop community partnerships to transition residents to the community.
- Work with the nursing home associations to gain their support of the grant activities including encouraging nursing homes in the pilot areas to sign "bed-hold" agreements to allow transitioning individuals to keep their bed while temporarily spending a few nights in the community.
- Involve nursing home social workers as part of the transition team.
- Coordinate with HUD and the local housing authorities to address housing issues
- Coordinate with advocacy groups, consumers, families, and other agencies in planning for proper transitions.
- Implement demonstrations initially in two geographical areas to determine best practices prior to statewide implementation. The project will initially be piloted in nine South Carolina counties with statewide implementation anticipated by the final year of the grant period.
Goal. Develop mechanisms to identify consumers desiring to return to the community.
- Use the Community Long Term Care unit's staff and case management database to identify potential transition clients.
- Coordinate with the Department of Disabilities and Special Needs to identify head and spinal cord injured nursing facility residents who wish to return home.
- Coordinate with the Department of Mental Health to identify persons in nursing facilities with mental illness who wish to return home.
- Develop outreach/education information on making referrals. A grant brochure has been developed outlining important facts about the project, including; services, target areas and eligibility requirements. The brochure is intended for potential project participants, nursing facility staff, as well as all others who provide care to the individuals we intend to serve.
Goal. Develop a set of services designed to build upon existing waiver and community services that will support transitioning consumers.
- Develop a Community Transition Nursing (CTN) service for people with short-term nursing facility stays. The grant-funded CTN will attend to matters of medical fragility of the project participants, once they return to community living, for up to 3 months following transition. The CTN will assist the consumer/family with a variety of medical matters, including identifying areas to train family members, as allowed in South Carolina's Nurse Practices Act.
- Incorporate appropriate mental health service package into the set of services available for transitioning residents. Grant participants, who transition from the state mental health hospital, will be offered housing in a mental health community where residential and rehabilitative services are available to help clients integrate into the community while addressing their clinical needs.
- Perform a continuous program evaluation to add or delete services from the set available to transitioning residents, as needed.
Goal. Evaluate the success of the NFT project, South Carolina Home Again, and determine how to conduct this as an ongoing effort after the grant period.
- During Year One of the grant, develop an internal evaluation instrument to assess which efforts are most successful.
- Assess each consumer's transition outcomes.
- Assess the effectiveness of the transition services in meeting program objectives.
- Develop a plan to continue statewide after the grant.
- Amend HCBS waivers as needed to include services identified.
Key Activities and Products
- Begin dialogue with area nursing facilities to lay groundwork for successful participation.
- Develop the comprehensive assessment instrument to be used in identifying and transitioning clients to the community.
- Expand the dialogue with HUD and local housing authorities in the target areas and develop a housing database.
- Initiate Community Transition Nursing and the mental health services package.
- Expand housing partnerships to include new HUD grant recipients for additional commitments.
- Use the comprehensive assessment instrument to identify potential transition clients.
- Assist a projected 20 residents with community relocation.
- Implement newly developed transitional services as needed and identified in the care plan.
- Conduct a year-end evaluation to determine progress and success.
- The Olmstead Task Force comprises various state government members, the South Carolina Housing Authority, provider groups, advocacy representatives and individual consumers.
- The statewide Grant Advisory Committee includes state agency representatives from the Department of Health and Human Services, Department of Mental Health, Department of Disabilities and Special Needs, and the Department of Social Services, as well as consumers/advocates representing the SC Spinal Cord Injury Association, SC Brain Injury Association, Continuum of Care for Emotionally Disturbed Children, Independent Living Centers, Alzheimer's Association, Mental Health and Mental Retardation Association, the nursing facility industry and senior advocacy groups.
Consumer Partners and Consumer Involvement in Planning Activities
The Olmstead Task Force was charged with developing the South Carolina long-term plan in response to the Olmstead decision. In addition to subgroup and committee work, public forums were held to attract and respond to the opinions and needs of consumers and their families. The Olmstead Task Force assisted with this grant process, and the grant application is a direct response to the Task Force recommendations. Update: This task force is no longer active.
Consumer Partners and Consumer Involvement in Implementation Activities
The statewide Grant Advisory Committee was created to provide ongoing involvement during grant development, implementation and evaluation.
- Public housing authorities in pilot areas.
- South Carolina Department of Mental Health (DMH).
- South Carolina Department of Disabilities and Special Needs (DDSN).
- South Carolina Governor's Office of Ombudsman.
- University of South Carolina, Center for Disability Resources.
- University of South Carolina, School of Public Health.
Private Partners and Subcontractors
- Community Transition Nursea registered nurse contracted to provide community transition and some telehomecare activities.
- South Carolina Health Care Association.
Public and Private Partnership Development/Involvement in the Planning Phase
The workgroup for the Nursing Home Transitions Grant includes staff from DHHS, representing the Bureau of Senior Services, the two Divisions of Community Long-Term Care, the Ombudsman Office, and the Division of Community and Facility Services. Also participating are staff from DMH, including the administrator of one of the DMH long-term care facilities and staff from the DDSN representing the Head and Spinal Cord Injury Division. This group identified nursing facility transition needs for this grant application.
None were involved.
Public and Private Partnership Development/Involvement in Implementation
- Three housing authorities in South Carolina are located in the initial target areas; two have agreed to assist in identifying housing options for transitioning individuals.
- South Carolina Department of Disabilities and Special Needs has agreed to enroll up to eight transitioning individuals per year in the HASCI waiver.
- The Ombudsman Office agreed to assist with distribution of information and other outreach activities.
- The University of South Carolina, School of Public Health will perform an independent evaluation of grant activities.
- The University of South Carolina, Center for Disability Resources will contract with the transition nurse and telehomecare grant activities.
South Carolina Health Care Association has verbalized its support of the grant activities which includes forming "bed-hold" agreements for transitioning individuals.
Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities
The activities proposed are coordinated and linked to both existing home and community programs and to other proposals South Carolina is developing.
- South Carolina will use existing Medicaid waiver programs as the primary source of services to consumers.
- Working in collaboration with the previously approved Real Choice for Systems Change Grant, the nursing home transition project plans to utilize "South Carolina Access" and "South Carolina Choice." "South Carolina Access" will be a statewide information and referral system database. "South Carolina Choice" is a demonstration waiver to test an enhanced method of offering self-directed care to clients served by Community Long-Term Care in the Spartanburg area. It will provide greater options with regard to the types of services and providers allowed to receive Medicaid reimbursement.
An oversight committee will not be utilized; instead grant oversight will be conducted internally.
Formative Learning and Evaluation Activities
Using the state's case management software, data will be collected to track consumers' status before and after transition. Data collected includes medical diagnosis, treatment and therapies, current medications, functional information and information regarding the client's psychosocial behavior. The information gathered is used to determine the client's current level of care. This data will also be used for an evaluation of how well the project activities are meeting goals and objectives, completed by project staff as part of their overview of the grant activities. The purpose will be to identify changes necessary to achieve successful transitions and enact those changes.
Evidence of Enduring Change/Sustainability
- Proposed infrastructure changes include the introduction and provision of new community supports such as CTN. If the cost analysis supports a cost savings, then South Carolina will consider implementing this service statewide.
- Services identified as helpful in the transition process will be incorporated into the waivers, allowing the continuation of this effort beyond the immediate grant period.
- A single comprehensive assessment instrument will be developed and be implemented at a cost that can be sustained on a permanent basis.
- The state hopes to make the bed hold transition agreement an enduring change.
- Expansion of current case management software to track nursing facility transition activities will be permanent, providing the information technology structure to perform and measure this activity after the grant.
- Expansion of the state's newly developed and implemented CareCall telephone verification system to submit and track transition service expenses by client.
- A sustainability plan to continue grant activities will be developed in Years Two and Three of the grant.
Two geographic areas will be targeted, covering nine counties in South Carolina in the Greenville/Spartanburg region and the Columbia region. Both areas contain a mix of rural and urban areas.