Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Involving and Collaborating with Key Stakeholders


To develop processes and procedures that will result in the successful relocation of nursing home residents who are appropriate for home and community settings, states need to take account of the interests of multiple stakeholders. Stakeholders include consumers, families, consumer advocates, nursing facility administrators and discharge planners, HCBS providers, Independent Living Centers, housing authorities, and state agency staff.

A good way of taking these interests into account, and thus increasing an NFT program’s chance of success, is to develop relationships and partnerships with these key stakeholders, particularly at the direct service level (e.g., the community organizations that provide services and supports), which can facilitate effective coordination of transition activities. Involving nursing facility provider associations in one project’s work group helped the project to succeed by allaying providers’ fears and gaining their support. Project staff also made presentations to individual nursing facilities to introduce the program and answer questions from administrators, directors of nursing, and social services staff; this strategy proved to be valuable, as about 85 percent of the project’s referrals came from nursing facilities.

Some stakeholders can assist the state Medicaid program with identifying the home and community service infrastructure necessary for a successful transition, and can help design service and support systems. It is important that the key stakeholders involved include individuals or groups with experience in moving people out of nursing facilities and that they be involved at the earliest feasible point in the process.

In general, states need to use two approaches to develop a successful and sustainable transition program: (1) a “top-down” approach that elicits the involvement and support of the leadership of key agencies to reduce barriers and urge cooperation; and (2) a “bottom-up” approach of fostering cooperative staff relationships in the field to facilitate referrals and address specific transition issues. Although efforts to involve stakeholders can be time consuming, the resulting goodwill and improved communication ultimately contribute to successful transitions.

Collaborating with Key Stakeholders: State Examples

New Jersey’s Community Choice counselors work in all of the State’s nursing homes and have developed invaluable collaborative relationships with nursing home social workers and admission staff. This collaboration enables dialogue and cooperation, thereby facilitating the transition process.

North Carolina established 16 regional coalitions to work on nursing facility transitions, and the Divisions of Medical Assistance and Vocational Rehabilitation Services, as well as Independent Living Centers, use state, local, and private resources to provide transition services.

Nebraska created transition partnerships statewide among all the State’s Area Agencies on Aging (AAAs) and nursing facilities to identify residents who were likely candidates for transition and to facilitate successful transitions for those candidates. The State also established a statewide toll-free number for nursing facility transition assistance that routes callers to the appropriate AAA.

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