Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Identifying and Educating Residents with the Desire and Potential for Transition


States must first establish the target population: all individuals or specific groups, such as those under age 60 who do not need a skilled level of care or those who at admission are at risk of losing their housing. Once the target population has been selected, states must then develop feasible and effective referral, screening, and assessment procedures to identify individuals who have the desire and the potential to be transitioned successfully to the community.

Money Follows the Person Policies: State Examples

Texas was one of the originators of the MFP concept. The State’s MFP policy enables individuals residing in nursing facilities to move back to a community setting and to utilize their entitlement dollars to receive HCBS, primarily through the Community-Based Alternatives waiver program. The Texas Health and Human Services Commission implemented the program September 1, 2001, and the policy was subsequently codified into law. The MFP policy has been highly successful in relocating individuals from nursing facilities to the community. As of December 31, 2007, 12,461 individuals had transitioned from nursing facilities.24

Maryland enacted the Money Follows the Individual Act, which requires admission to an HCBS waiver program if (1) an individual is living in a nursing home at the time of the application for waiver services, (2) the nursing home services for the individual were paid by Medicaid for at least 30 consecutive days immediately prior to the application, (3) the individual meets all of the eligibility criteria for participation in the waiver program, and (4) the home and community services to be provided to the individual will qualify for Federal matching funds.

There is no single profile of a nursing facility resident who would be considered a good candidate for transition. Individuals of all ages with many different diagnoses and varying disability levels have successfully transitioned. However, some factors are considered essential for an individual’s successful transition: motivation for discharge, community supports, and available housing. People who lost their home during a nursing home stay and those whose home is not accessible can find it difficult to transition.

Some states have used the nursing home minimum data set (MDS) or other screening and assessment tools to identify potential candidates.25 The MDS is a core set of screening and assessment elements that forms the foundation of the comprehensive assessment for nursing facility residents. By looking at factors captured in these data sets--such as medical needs, functional status, desire to transition, and length of stay--transition programs can screen for potential candidates, who can then be further assessed for transition.

Using MDS data in this manner, while a useful step, is by no means sufficient. Many individuals who are good candidates for a transition program may not show up in the initial screening, and some of those who do may face insurmountable transition barriers. Therefore, programs should not rely solely on screening tools but should work with persons and groups who know the nursing home residents. Such knowledge can make them invaluable sources of information to identify appropriate transition candidates.

Minnesota enacted legislation in 2005 requiring its Department of Human Services to develop a methodology for sharing MDS data with Independent Living Centers to assist them in identifying institutional residents who want to live in the community.26

North Carolina added a transitions protocol to the Medicaid Uniform Screening and Assessment Tool, and obtained a Data Use Agreement Amendment that allows the State to use MDS data to identify those wanting to transition.27

Nursing home ombudsmen, Independent Living Centers, protection and advocacy organizations, and other local groups and programs can also serve as important partners in the identification process. A number of states use Independent Living Centers to both assist in the identification of individuals and with the transition process. The expertise and capabilities of such community organizations should be tapped early on to ensure effective collaboration.

Based on the experience of Systems Change NFT Grantees, the following methods have proved to be most effective in identifying individuals with the highest potential for community living: (1) targeted outreach and education by local transition coalitions to nursing facility staff, including administrators, social workers, discharge planners, and directors of nursing; (2) outreach activities for residents of nursing facilities; and (3) education of and collaboration with regional nursing facility ombudsmen.28

Use of Peers to Facilitate Transition

Utah developed a statewide network of trained ILC transition coordinators and peer mentors who can provide information to any nursing home resident contacting an Independent Living Center for transition services.

State transition program staff should anticipate some resistance to transition activities among nursing home staff and family members. Several Systems Change NFT Grantees considered such resistance to be a major transition barrier. Some nursing facility staff do not believe that individuals with extensive functional limitations or medical and nursing needs can be safely served in the community. In addition, some nursing facilities may actively resist transition efforts, believing that such efforts will decrease their occupancy rates and profitability. Even if families do not oppose their relative’s transition, their ability to support it and/or provide informal care depends on a wide range of factors, including work commitments, available time and money, distance from their home, and the age of any dependent children. In some instances, family members may not want to provide informal care, particularly if the relative’s admission to a nursing facility followed many years of informal care at home and caregiver “burnout.”

Dealing with resistance can require considerable time and effort, and in some cases such resistance may pose an insurmountable transition barrier, particularly if the individual seeking transition has extensive needs and no family or friends willing or able to provide informal care. (See the Resources section of this chapter for publications describing nursing facility transition programs.)

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