NH Community Passport Program - CASE STUDY (HCBC-CHOICES FOR INDEPENDENCE WAIVER) For seven years Jeannette Gendron was a resident of the Hillsborough County Home in Goffstown. A native of Manchester, as a young woman Ms. Gendron worked in the city s mills. After the textile industry pulled out of New Hampshire, Ms. Gendron held a variety of jobs including working as a housekeeper for area hotels and nursing homes, a kitchen aide in a school cafeteria, and a babysitter. Married only briefly, Ms. Gendron lived with her parents until their deaths, caring for them in their later years. When she was 72 Ms. Gendron suffered a serious heart attack. On the advice of her doctor, who felt that a nursing facility could best address her medical needs, Ms. Gendron moved to the Hillsborough County Home. A Medicaid patient, Ms. Gendron came to the County Home with a number of health issues. She required medication for high blood pressure, congestive heart failure, arthritis, and a stomach ulcer. A survivor of breast cancer, she had undergone a double mastectomy. In addition, she had a hip replacement and still experienced difficulty walking. Although a long-term patient at the County Home, Ms. Gendron continued to miss living in the community and the independence of being in her own apartment. Ms. Gendron learned about Waiver program and the New Hampshire Community Passport project when a volunteer from the Office of Long Term Care Ombudsman (OLTCO. Ms. Gendron was excited about the possibility of participating in NHCP and requested assistance to move back to her old neighborhood. The County Home RN had just recently completed the MDS 3.0 Sect Q and had identified Ms. Gendron as a feasible discharge. The Discharge Planner met with Ms. Gendron to complete the Medical Eligibility application and assessment and submitted the forms to the New Hampshire Bureau of Elderly and Adult Services (BEAS) Long-Term Care Unit (LTCU). The Discharge Planner contacted ServiceLink as the Local Contact Agency for NH to refer Ms. Gendron to the Long Term Care Counselor to hear about other possible resources in her community she might be able to utilize for support. ServiceLink received the referral and contacted the Community Passport Program Transitional Coordinator as Ms. Gendron had Medicaid, and was in the nursing facility well over 3 months. The NHCP Transitional Coordinator consulted with the BEAS Nursing Supervisor and a planning team was formed that included an OLTCO volunteer, the BEAS Nursing Supervisor, County Home staff, NHCP Transitional Coordinator, and Ms. Gendron invited a friend to attend this meeting with her. The planning team held its first Community Living Assessment meeting at the facility with Ms. Gendron to discuss her preferences for supports, evaluate the risks of moving back to the community, and determine whether adequate community services would be available to address her needs. There were areas of needed support identified that Ms. Gendron would require but did not have support for. For example, Ms. Gendron did not have an apartment to return to, she was very nervous about the fact she had not cooked for herself in over 5 years, and what would happen to her if she were alone and fell. Ms. Gendron could transfer herself independently and she was very alert and bright. The risks and barrier assessment was conducted and a Community Living Call was conducted. As a result of the Community Living call a person-centered transition plan was developed. The plan set out the overall transition goals for Ms. Gendron, outlined the tasks that needed to be accomplished or supports that needed to be found in order for her to move to the community, established a tentative timeframe for completion of these activities, and identified interim services that needed to occur prior to discharge. This included the following; to find housing; to complete a medication instruction program with the nursing facility staff, to continue working with PT/OT in regards to her strength and independent living skills. The BEAS Nursing Supervisor, the NHCP Director, and NHCP Transitional Coordinator reviewed Ms. Gendron s case. It was determined that Ms. Gendron was a good candidate for the New Hampshire Community Passport program. However with housing as a barrier, it would take some work to find her a place to live in the community. The Transitional Coordinator spoke with the facility discharge planner to fill out a Section 8 Housing voucher with Ms. Gendron, and to indicate she was residing in a nursing institution to prioritize her receiving the Section 8 Voucher. TheTransitional Coordinator contacted known elderly housing in Manchester and the local area to inquire of any openings. Within 6 weeks an opening in elderly housing became available to Ms. Gendron. Ms. Gendron did not have a security deposit, however with the NHCP involved, the Transitional Coordinator was able to speak with the apartment manager to assure that the program could provide the security deposit needed for her to move in the following month. A discharge date was set at the end of the next month. Ms. Genrdon worked with her discharge planner and the paperwork was signed for her apartment lease. 1
The BEAS Nursing Supervisor informed Ms. Gendron that a Transitional Case Manager (tcm) would be assigned to work with her during the transition process. The tcm would help her with any other apartment needs, set up and obtain community services, and assist with any other arrangements that were needed in order for her to move into the community. As Ms. Gendron had no prior experiences with case management and did not have a preference of providers, the BEAS LTCU used the agency s assignment rotation process to designate a tcm to work with her. Under the program, the tcm s services will end when Ms. Gendron is settled in her new home and ongoing waiver case management services will be activated. Ms. Gendron will have the choice of having her tcm continue as her Case Manager in the community, requesting a specific Case Manager, or having a Case Manager assigned through the BEAS assignment rotation process. With her health stable, Ms. Gendron s was ready to move back to Manchester. She and the nursing facility discharge planned worked with the NHCP Transitional Coordinator to identify furniture and other houshold needs, first week of groceries, medical equipment needed and any modifications needed for the new apartment. In addition to working with a tcm, Ms. Gendron also met with a BEAS Adult Services (AS) Social Worker. The APS Social Worker provided an additional and impartial observation of Ms. Gendron s understanding of the transition process and assessed her needs to assure that the plan that had been developed was adequate. In her meeting with Ms. Gendron, the APS Social Worker explained that she would help Ms. Gendron consider different aspects of moving to the community. As a result, Ms Gendron had a clear understanding of the transition process, the services she would need in the community, and the risks associated with her transition. In this discussion, Ms. Gendron disclosed that her youngest son had been asking her for money more frequently and that she was certain he was using it for drugs. The social worker discussed resources and explained that she would be moving to a locked building. She could decide to see him or not in the community. The APS social worker also offered to see her in the community once she was discharged since the dynamic with her son seemed to worry her. This process helped Ms. Gendron, as well as her team, feel comfortable that her comprehensive care plan and community living setting would address her needs. This plan identified remaining transition tasks, items that still needed to be purchased, and services that needed to be in place before Ms. Gendron left the County Home. The tcm then worked with Ms. Gendron and helped her to complete all required paperwork for the waiver program (consents and signing of the support plan). The Transitional Coordinator arranged for a bed and a kitchen table to be delivered to the apartment. Ms. Gendron chose a congregate housing residence and the tcm went with Ms. Gendron to look at it before discharge. Ms. Gendron was pleased with the apartment. The nursing facility OT had met the tcm and the resident at the apartment to conduct a home evaluation to ensure she could use the new bed. The tcm emailed the Transitional Coordinator about moving the other needed household goods Ms. Gendron had placed in storage when she entered the County Home into her new apartment. The Transitional Coordinator authorized payment for moving costs. A discharge planning meeting was set again to review activity with the discharge planning team and to evaluate the transition s progress. Additional tasks were identified and assigned for completion The friend volunteered to drive Ms. Gendron to the new home, the facility Discharge Planner would work with Ms. Gendron to make arrangements with the Transitional Coordinator to get a grocery gift card to pick up a weeks worth of food for the apartment, and the Transitional Coordinator would ensure all furnishings had been delivered prior to the day of her arrival. The tcm would set up her LifeLine, refer to Meals on Wheels, set up PCP appointments, and ensure all community health care providers had been given sufficient time to begin services the very next day. The facility discharge planner discussed Ms. Gendron s concern regarding meal preparation. Ms. Gendron reported she wanted to cook for herself as she had done this for 60+ years of her life prior to the facility. Congregate offered late afternoon meals and Ms. Gendron reported she would try it. This meeting provided confirmation that Ms. Gendron had successfully completed medication management training. The Transitional Coordinator offered a pharmacy packaging service to assist with dosages. Ms. Gendron s ongoing services included case management, personal care, meals, lifeline support, and nursing. With her housing already secured, a discharge date was set. The tcm finalized arrangements for needed community services and arranged for the apartment s utilities to be turned on the day before the move. The Transitional Coordinator also conducted a home inspection on the day before Ms. Gendron s 2
discharge to be sure that the household furnishings were in place, and that the utilities (including lifeline) were operational. On move-in day, the tcm met with Ms. Gendron in her new home. Ms. Gendron had requested that her tcm continue as her Case Manager in the community. Had a different Waiver Case Manager been assigned, this person would have been included in the discharge-planning meeting and also would have met Ms. Gendron at her home. In this case, the move-in day would mark the end of tcm s involvement. Three weeks after her move to the community, the APS Social Worker visited Ms. Gendron in her apartment to make sure that she was satisfied with her living arrangement and that things were going well. Confident that Ms. Gendron was settled and her services were in place, the Social Worker explained that she would no longer be coming to see her. The Waiver Case Manager provides Ms. Gendron s ongoing case management services and works with her to assure that she receives the services and supports that she needs. The Transitional Coordinator stays in contact with the CM and the individual throughout the year. 3
The Money Follows the Person, The NH Community Passport Program Enacted by the Deficit Reduction Act of 2005, the Money Follows the Person (MFP) Rebalancing Demonstration is part of a comprehensive, coordinated strategy to assist States, in collaboration with stakeholders, to make widespread changes to their long-term care support systems. With the history and strength of the Real Choice Systems Change (RCSC) grants as a foundation, this initiative aims to assist States in their efforts to reduce their reliance on institutional care, while developing community-based long-term care opportunities, enabling the elderly and people with disabilities to fully participate in their communities. In 2007, CMS awarded $1,435,709,479 in MFP grants with States proposing to transition over 34,000 individuals out of institutional settings over the five-year demonstration period.30 States and the District of Columbia were awarded grants. The NH MFP program revolves around the person-centered planning philosophies Piggybacks Home and Community Based Care waivers. NH also just recently revised the program this year to include specifically individuals eligible for behavioral health state plan services coming out of IMDs. CMS mandated that individuals be eligible for the state waiver program or the behavioral health plan services to ensure people participating in the program would receive community health care services upon discharge and thereafter. The program follows individuals for one full year. For all individuals who are eligible and transition the state receives an enhanced federal fund match (25/75 verses the traditional 50/50) to help with the payment of the community service received by the individual. Of the four state waiver programs, The Choices for Independence (CFI) program offers demonstration services, which assist with home furnishings, furniture, security deposit, moving expenses and other transition related items. The transitional coordinator works closely with multiple care partners to conduct discharge and transition planning for safe discharge. The program uses a risk and barrier assessment process and form to assess potential challenges and support gaps. Program spans the medical and social services systems The program works to leverage available services in the specific area or community the individual is transitioning to. The program attempts to solicit partners, networks and services offered by those services to create a support network tailored to the individuals in the program. The program is statewide. So, obviously there is a range of services offered in varying communities that are either/or or both medical and social services. The transition meetings are extremely crucial in figuring out who will conduct the tasks needed to actually get to the point of discharge, as well as identifying the 4
community support team (formal and informal caregivers), planning for emergencies and creating back-up plans. Partnerships with duplication: The care partnerships are crucial to the success of the transitions. Almost all of the transitions are individuals with relatively high medical acuity. They generally need multiple providers and the help of family or informal care providers. The Passport Program works with the individual, the family, friends, the nursing facility, community partners such as case management agencies, area agencies, Centers for independent Living (GSIL), ServiceLink, and other LCA s. Target populations include HCBS waiver and specific state plan behavioral health services eligible who have been in a nursing institution for 3 months or more and on Medicaid one day Resources for more info: https://www.cms.gov/deficitreductionact/20_mfp.asp http://www.dhhs.nh.gov/dcbcs/beas/nhcp/ https://www.cms.gov/communityservices/10_communitylivinginitiative.asp 5