U.S. Department of Health and Human Services
Partnerships for Community Living: Florida's Nursing Home Transition Program
Michael Schaefer and Steve Eiken
MEDSTAT
December 23, 2003
PDF Version: http://aspe.hhs.gov/daltcp/reports/2003/FLtrans.pdf (20 PDF pages)
This report was prepared under contract #HHS-100-97-0019 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The MEDSTAT Group. Additional funding was provided by the Center for Medicare and Medicaid Services. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.
The opinions expressed in this report are those of the authors and do not necessarily reflect the views of ASPE, CMS or Medstat. The authors gratefully acknowledge the many people in Florida who generously gave us their time and insights for the preparation of this report.
TABLE OF CONTENTS
BACKGROUND--THE BRAIN AND SPINAL CORD INJURY PROGRAM
Identifying Program Participants
Transition Coordination
Payment of Up-Front Costs
Coordinating with Nursing Homes
Obtaining Housing
Obtaining Housing and Community-Based Services
LIST OF CHARTS
CHART 1: Florida Nursing Home Transition Grant Project: Participant Living Arrangement
LIST OF TABLES
TABLE 1. Geographic Focus of Partnerships for Community Living
INTRODUCTION
The Centers for Medicare & Medicaid Services (CMS), in association with Office of the Assistant Secretary for Planning and Evaluation (ASPE), sponsored the Nursing Home Transition Demonstration Program to assist states in providing transition options to nursing home residents who wish to move back to the community. CMS and ASPE awarded grants to 12 states between 1998 and 2000.1
The Demonstration permitted states to use grant funds for virtually any direct service or administrative item that held promise for assisting nursing home residents' return to the community. The grants provided targeted administrative or service resources to achieve the following objectives:
- To enhance opportunities for nursing home residents to move into the community by identifying nursing home residents who wish to return to the community and educating them and their families about available alternatives;
- To overcome the resistance and the barriers that may be in the way of their exercising this choice; and
- To develop the necessary infrastructure and supports in the community to permit former nursing home residents to live safely and with dignity in their own homes and communities.
This report, which describes Florida's Nursing Home Transition Grant Project, is one of a series of nine case studies presenting results from the Demonstration. The case studies, along with a final report summarizing results from all these states2, provide useful information as states consider nursing home transition efforts or implement nursing home transition programs. Lessons the demonstration states learned during this program are particularly important because CMS awarded a number of Nursing Home Transition grants in 2001 and 2002 under the Systems Change Grants initiative.3
During a September 2002 site visit, Medstat interviewed project staff from the two state agencies that administered the grant--the Agency for Health Care Administration and the Brain and Spinal Cord Injury Program (BSCIP) in the Department of Health. Medstat also interviewed staff from three advocacy organizations and one assisted living provider involved in the project, as well as three consumers who transitioned to the community with the help of the program. The State of Florida provided additional information for this report through grant reports.4
This case study report focuses on three common components of nursing home transition programs:
- transition coordination or case management to help consumers access housing and services in the community;
- a fund to pay for the up-front costs consumers may incur as they leave a nursing home, such as a security deposit for an apartment; and
- a method to identify nursing home residents interested in transition.
The report also describes how three challenges common among the demonstration programs--coordinating with nursing homes, obtaining community housing, and obtaining home and community-based services--affected the nursing home transition grant, and how state and local program staff addressed these challenges. Finally, the report presents data on the program's results and describes BSCIP's subsequent efforts to support nursing facility residents interested in transition.
BACKGROUND--THE BRAIN AND SPINAL CORD INJURY PROGRAM
Florida targeted this grant to people with brain or spinal cord injuries served by BSCIP, which is part of the Florida Department of Health (DOH). This program supports a coordinated, statewide service system including case management, acute care, inpatient and outpatient rehabilitation, transitional living, assistive technology, and home and vehicle modifications. BSCIP operates a Medicaid home and community-based services (HCBS) waiver to provide ongoing supports for people who qualify for nursing home services. BSCIP also supports education, prevention, and research activities. BSCIP serves people with traumatic brain injuries or spinal cord injuries (TBI/SCI) between the ages of 18 and 55 regardless of income level.
Hospitals are required to notify BSCIP when someone suffers a traumatic brain injury or spinal cord injury. Once this happens, a BSCIP case manager contacts the individual within 10 working days. The case manager works with the individual and his or her family to determine eligibility for BSCIP and to provide information about available federal, state, and community resources. If appropriate, the case manager will develop and help implement an individual community reintegration plan. The case manager follows up with the person until he or she is reintegrated into the community or until the person is a long-term nursing facility resident with little prospect for discharge. The case managers are located in BSCIP regional offices throughout the state.
Except for the Medicaid HCBS waiver, Florida finances BSCIP through the BSCIP Rehabilitation Trust Fund, which collects a percentage of traffic-related fines, surcharges from convictions of driving or boating under the influence, and fees from temporary motor vehicle license tags.
PROGRAM DESCRIPTION
Florida received a Nursing Home Transition Demonstration Grant of $500,000 in September 2000. The state's Medicaid agency, the Agency for Health Care Administration, was the official grant recipient and was responsible for oversight of grant activities, federal reporting, and contract management. BSCIP was responsible for day-to-day grant administration. The project targeted nursing home residents eligible for both Medicaid and BSCIP. The program's goal was to transition 45 individuals into community settings. The program focused on ten counties in six geographic areas described in Table 1.
| TABLE 1. Geographic Focus of Partnerships for Community Living | |
| Area | Counties |
| Northwest (includes Pensacola) | Escambia, Santa Rosa, Okaloosa |
| Northeast (includes Jacksonville) | Duval |
| Central (includes Orlando) | Orange |
| Tampa-St. Petersburg | Hillsborough, Pinellas |
| South (includes Fort Lauderdale, and Palm Beach) | Broward, Palm Beach |
| Miami-Dade County | Miami-Dade |
Florida earmarked almost two-thirds of the grant award ($315,000) for transition funds to pay for up-front costs people need when establishing a community household. The state spent the remaining funds on project staff ($90,000), a subcontractor to identify best practices in nursing home transition ($45,000), a contract with the Florida Housing Coalition to provide housing training to the transition coordinators ($40,000), and staff travel ($10,000).
Florida received the grant in September 2000, but the program did not start until September 2001. Florida's was not able to transfer funds from the Agency for Health Care Administration to BSCIP because the state legislature had not authorized BSCIP to spend the federal grant funds. BSCIP obtained this authorization almost a year after Florida received the grant.
Identifying Program Participants
BSCIP followed a transition candidate identification process mandated by the Florida legislature. Title XXIX, Chapter 381, Section 77 of the 2003 Florida Statutes requires that:
The department [of health] shall conduct an annual survey of nursing homes in the state to determine the number of persons 55 years of age and under who reside in such homes due to brain or spinal cord injuries. All persons identified in such a survey shall be evaluated as to their rehabilitation potential, and any person who may benefit from rehabilitation shall be given an opportunity to participate in an appropriate rehabilitation program for which she or he may be eligible.
When BSCIP began, program staff could provide little assistance to help people move to the community, because no funding was available for home and community-based services or for the services and items many people need to reestablish a community residence. The mandated survey process successfully identified potential candidates for transition, but only raised residents' hopes without providing them the means to actually move into the community. BSCIP improved its ability to support nursing home transition when Florida started a Medicaid HCBS waiver for people with TBI/SCI in the late 1990s. This waiver enables BSCIP to fund long-term supports for people living in the community. The Nursing Home Transition Grant Project provided additional assistance to help people identified in this survey.
In 2001, Florida conducted the survey by mailing out a questionnaire to all nursing facilities in the state. When the survey was completed, BSCIP had a list of potential candidates for transition to the community. While the legislature required conducting the survey, it did not require nursing homes to respond. Many nursing homes did not respond. BSCIP tried to increase nursing homes' response with follow-up phone calls 30 and 90 days after the survey was sent and by faxing additional surveys if needed.
After receiving the 2001 survey results, BSCIP staff administered an in-person interview and assessment with assistance from two external consultants experienced in working with people with TBI/SCI. First, interviewers assessed the person's community support and the availability of housing should they transition out of the facility. Second, interviewers collected information regarding the candidate's demographics, health status, service needs, and psychosocial status. One interviewer said that the face-to-face contact was crucial because it allowed him to observe additional clues about a resident's physical, psychosocial, and behavioral condition and environment.
At the end of the assessment, the interviewers estimated the cost of products and services the consumer would require if he or she moved into the community, and recommended whether the grant should assist the consumer in nursing home transition. Interviewers and lead BSCIP staff then met to decide which candidates should receive transition assistance. The critical tool for selecting transition candidates was a one-page rating system the interviewers used to measure a candidate's available community support and housing. The program selected nursing home residents with access to housing and support from family and friends.
In addition to the nursing home survey, Florida used two additional sources to identify transition candidates. Beginning in July 2000, the Brain Injury Association of Florida and the Florida Spinal Cord Injury Resource Center began keeping detailed files on long-term nursing facility residents who had previously received support from BSCIP. BSCIP staff used the information to identify nursing home residents with TBI/SCI who may be able to transition. Program staff also received referrals from nursing home staff and residents when visiting nursing facilities to assess people identified in the survey.
Transition Coordination
The state assigned a state-employed BSCIP case manager to coordinate the transition for each nursing home resident it selected for the Nursing Home Transition Grant Project. First the case manager asked the resident if he or she was interested in transition. For interested consumers, the case manager developed a community reintegration plan with the consumer, and arranged for housing and services. BSCIP's trust fund was available to pay for any rehabilitation or other restorative services necessary before transition.
State staff said one project design flaw was the lack of designated transition coordinators and the reliance on BSCIP case managers who coordinate services for all BSCIP participants and commonly serve between 100 and 175 people. Several state and regional BSCIP staff recommended full-time case managers focused on long-term care services, including the Medicaid HCBS waiver for people with TBI/SCI and nursing home transition.
In certain instances, BSCIP case managers worked with support coordinators to assist transitioning nursing facility residents. Support coordinators are private contractors that typically assist people using the Medicaid waiver for people with TBI/SCI. Under the waiver, once the case manager and the participant establish a plan of care, the case manager helps the person identify a support coordinator. The support coordinator then meets the person monthly to ensure that the plan of care is being followed. During the transition process, support coordinators assisted participants in some time-consuming tasks such as locating accessible housing and purchasing household items.
Payment of Up-Front Costs
The Nursing Home Transition Grant Project used grant funds to pay for transition services through two methods. The first method was the typical purchasing system for the state. The BSCIP regional office completed a purchase order and sent it to the central BSCIP office in Tallahassee for approval. State staff reported the requisition order process was slow for nursing home transition and at times delayed transitions. Time was a crucial factor for many up-front costs, especially those related to housing (i.e. rent payments, and security deposits).
Florida developed a second, quicker transition expense payment option. At approximately the same time that the Nursing Home Transition Grant Project started, the Department of Health, including BSCIP, started using Visa purchase cards (called P-Cards) to purchase office supplies. BSCIP provided each regional office a P-Card and a $5000 credit limit. In addition to purchasing office supplies, BSCIP used the P-Card to purchase nursing home transition services. The P-Card enabled BSCIP to purchase household items and make security deposits or rent payments immediately, without waiting for central office approval or reimbursement. Also, many vendors trusted a Visa card more than a check or a requisition order form. BSCIP's use of the P-Card for transition services was a pilot test for potential usage in other programs throughout state government.
The Department of Health established an electronic coding system to ensure BSCIP could spend grant funds using the P-Card, and to ensure proper use of grant funds. When a case manager made a purchase, the credit card company sent an electronic prompt to the central office within five business days. BSCIP designated a few people at each regional office to review purchases for appropriateness and to ensure grant funds were used to pay the credit card bill for nursing home transition purchases.
Coordinating with Nursing Homes
The program's main entrée into nursing homes was the state-mandated nursing home survey described earlier in this report. Project staff and contractors then interviewed residents the nursing homes identified in survey. BSCIP set a protocol for approaching the facilities in a professional and non-threatening manner. State staff informed facilities about the grant project through informational mailings and advance phone calls before scheduling a resident interview at the facility. Interviewers displayed Department of Health badges at nursing homes to show credibility. Interviewers also explained that they were not going visiting the facility for evaluative or regulatory purposes.
State staff reported little resistance from the facilities they visited. Any nursing home resistance may have been from facilities that did not to respond to the BSCIP survey. State staff estimated only half the facilities responded to the survey, and that some responding facilities did not identify all residents with TBI/SCI.
Obtaining Housing
Project staff at every level said a lack of affordable, accessible housing was one of the most significant barriers to transition. BSCIP staff and others said local public housing authorities had long waiting lists for public housing, and that U.S. Department of Housing and Urban Development (HUD) Section 8 vouchers were in short supply.
BSCIP forged relationships between its case managers and housing advocacy groups so the case managers could more easily find housing for project participants. For example, the grant paid for the Florida Housing Coalition to provide training workshops and technical assistance for case managers. The Florida Housing Coalition and BSCIP also worked with public housing authorities to increase home and apartment accessibility for people with TBI/SCI. They have also explored alternative housing options, such as encouraging small group homes (i.e., two or three people) for persons with TBI/SCI. Another grant contractor, the Florida Alliance for Assistive Services and Technology (FAAST), produced the Florida Housing Resource Guide. This guide explains the complex processes necessary to qualify for low-income housing assistance and to plan and develop new public housing. BSCIP distributed the 30-page guide to BSCIP case managers.
One new housing option for former nursing home residents was an assisted living facility that set aside an entire wing for persons with TBI/SCI. BSCIP encouraged this facility to develop the wing because they expected some transitioning residents to prefer or need community residential services like assisted living. The wing's staff worked exclusively in that wing and was specially trained to work with people with TBI/SCI. Facility staff said they provided training and other supports to help people live more independently at the facility or to prepare them for moving to an apartment. The wing had 11 beds and had served ten Nursing Home Transition Grant Project participants as of August 2003.
Florida also used HUD Section 8 vouchers from Project Access, a project that awards vouchers targeted to former nursing home residents under age 62. HUD awarded ten vouchers to the Miami-Dade Housing Authority in December 2001. Miami-Dade County was not part of the grant's original coverage area, but BSCIP expanded the program to this county after it received these vouchers.
BSCIP and AHCA offices in Miami entered into a cooperative arrangement with housing advocates and advocates for people with disabilities to coordinate the vouchers' use. Five of the vouchers were initially allocated to BSCIP participants; the other five vouchers were allocated to the local Center for Independent Living (CIL) to use for people with disabilities other TBI/SCI. Unlike BSCIP, the local CIL had no dedicated funds to cover transition expenses, and Medicaid HCBS waiver services were not readily available for the CIL's consumers after their transition. The CIL had difficulty utilizing the housing vouchers, so it agreed to allow BSCIP to use two more Section 8 vouchers for a total of seven.
As of September 2002, only one person with TBI/SCI had moved to the community using a Project Access voucher. A significant challenge was finding landlords with accessible housing who accepted the vouchers. Some landlords who accepted vouchers did not have accessible housing, and three consumers were waiting for home modifications to make properties accessible.
Obtaining Home and Community-Based Services
Most transitioned consumers used Florida's Medicaid HCBS waiver for people with TBI/SCI, which BSCIP operated. TBI/SCI waiver services included assistive technology, attendant care, behavioral programming, case management, companion services, community support coordination, environmental accessibility adaptations, life skills training, personal adjustment counseling, personal care, and rehabilitation engineering evaluation. Florida also offered waivers to serve people with physical disabilities, but state staff said these waivers did not offer enough services to support people with TBI/SCI in the community.
The waiver for people with TBI/SCI had a waiting list, but Florida prioritized its waiting list so nursing home residents had first priority and could access waiver services immediately upon discharge. People at imminent risk of nursing home admission had second priority, followed by people who would benefit from waiver services but who are not at imminent risk of nursing home admission.
PROGRAM RESULTS
The Nursing Home Transition Grant Project expired on September 2003. Through the survey process and other referrals, the program identified and assessed 227 nursing home residents. Of the 227, the state selected 54 (24 percent) to participate in the transition program. Six of the 54 potential participants withdrew from the program and two passed away. The remaining 46 participants moved to community residences. Almost three-fourths of the transitioned consumers had spinal cord injuries (32, or 70 percent), while 12 had traumatic brain injuries.
Two-thirds of transitioned consumers (67 percent) moved to an apartment or home with another person (see Chart 1). The most common arrangement was living with a family member or friend (19, or 41 percent), but several people also lived with a roommate (12, or 26 percent). Thirteen transitioned participants lived in community residential settings: ten people in the assisted living facility with a wing for people with TBI/SCI and three people in small group homes.
| CHART 1: Florida Nursing Home Transition Grant Project: Participant Living Arrangement |
 |
NEXT STEPS
Before the grant expired in September 2003, BSCIP established a permanent Institutional Transition Initiative to continue nursing home transition assistance. The grant's project coordinator now coordinates this initiative. The BSCIP Rehabilitation Trust Fund pays for transition assistance, which is now one of BSCIP's permanently funded core services.
Before the grant, BSCIP stopped working with people considered to be long-term nursing home residents. Now, the project coordinator and the regional office administrator review a long-term resident's records at 30, 60, 90, 180, and 365 days after the person is considered a long-term resident. The project coordinator and administrator contact local BSCIP supervisors with questions if the files do not provide enough information to justify long-term institutionalization. Also, BSCIP now requires case managers develop a plan for helping a long-term resident transition if his or her condition improves. If the person's condition improves or circumstances change to make community living more likely, a BSCIP case manager initiates transition assistance.
BSCIP is also working with the state's Centers for Independent Living (CILs), the Florida Alliance for Assistive Services and Technology (FAAST), and public housing authorities to improve housing coordination. The plan is for people with disabilities to register at CILs, who will maintain a database of people with housing needs. Public housing authorities will notify FAAST of housing opportunities, and FAAST will inform the CILs. The CILs will then notify people in the housing database who are appropriate for the housing opportunities.
As part of the grant, Florida is developing a Best Practices Manual for nursing home transition, based on Florida's experience and on nursing home transition experience in other states. BSCIP expects the manual to be a guide for improving state nursing home transition systems and for local transition coordination. The state expected to complete the manual by January 2004.
BIBLIOGRAPHY
Hutto, Pamela. "Nursing Home Transition Grant" Prepared for Medstat site visit. Florida Agency for Health Care Administration. September 2002.
Hutto, Pamela. "Nursing Home Transition Grant: Status Report" Florida Agency for Health Care Administration. August 2003.
INTERVIEWS
Florida Brain and Spinal Cord Injury Program Kris Shields Dan Newman
Florida Brain and Spinal Cord Injury Program (St. Petersburg Office) Scott Homb Lucy Strickland Henry Wilson
Florida Brain and Spinal Cord Injury Program (Miami Office) Marilyn Larrieu Maribel Doll
Florida Agency for Health Care Administration Pamela Hutto
Florida Agency for Health Care Administration (Miami Office) Judy Rosenbaum
Hanna Oaks Assisted Living Facility John Perkins Evan Coutts Lois Bosworth
Brain Injury Association of Florida Joe DiDomenico (working for Self-Reliance, Inc. at the time of the interview)
Florida Housing Coalition Mike Shafer
Florida Spinal Cord Injury Resource Center Don Dawkins
Three consumers
NOTES
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In 1998, Colorado, Michigan, Rhode Island, and Texas received grants between $160,000 and $175,000 each. In 1999, New Hampshire, New Jersey, Vermont, and Wisconsin received grants of $500,000 each. In 2000, Arkansas, Florida, Pennsylvania, and Nebraska received grants of $500,000 each.
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Eiken, Steve and Burwell, Brian. Final Report of the Nursing Home Transition Demonstration Grants Case Study. Medstat: publication pending.
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Twenty-three states and ten centers for independent living received nursing home transition grants in 2001 and 2002. More information is available at the following Web site: http://www.cms.hhs.gov/systemschange/default.asp.
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References for these reports can be found in the bibliography.
COMPLETE LIST OF SITE VISIT REPORTS
Community Choice: New Jersey's Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/NJtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/NJtrans.pdf
Fast Track and Other Nursing Home Diversion Initiatives: Colorado's Nursing Home Transition Grant
HTML http://aspe.hhs.gov/daltcp/reports/2003/COtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/COtrans.pdf
Michigan's Transitioning Persons from Nursing Homes to Community Living Program
HTML http://aspe.hhs.gov/daltcp/reports/2002/MItrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2002/MItrans.pdf
One-to-One: Vermont's Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/VTtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/VTtrans.pdf
Partnerships for Community Living: Florida's Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/FLtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/FLtrans.pdf
Passages: Arkansas's Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/ARtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/ARtrans.pdf
Pennsylvania Transition to Home (PATH): Pennsylvania's Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/PAtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/PAtrans.pdf
Project CHOICE (Consumers Have Options for Independence in Community Environments): Texas' Nursing Home Transition Program
HTML http://aspe.hhs.gov/daltcp/reports/2003/TXtrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2003/TXtrans.pdf
The Homecoming Project: Wisconsin's Nursing Home Transition Demonstration
HTML http://aspe.hhs.gov/daltcp/reports/2002/WItrans.htm
PDF http://aspe.hhs.gov/daltcp/reports/2002/WItrans.pdf
To obtain a printed copy of this report, send the full report title and your mailing information to:
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