1. Peers: Agents of Change in Deinstitutionalization in New York State
Open Doors Transition Center Project Peer Outreach and Referral Program A project of NYS Money Follows the Person
Peers: Agents of Change in Deinstitutionalization in New York State
NYS Care Management Coalition: 2017 Annual Training Conference
Niagara Falls, NY
May 10, 2017

3. New York Association on Independent Living (NYAIL)
Statewide, not-for-profit membership association of Independent Living Centers
ILCs are unique disability-led, cross-disability, locally administered not-for-profit organizations, providing advocacy and supports to assist people with disabilities of all ages to live independently and fully integrated in their communities
ILCs have been transitioning and diverting people from institutions for more than 20 years
ILC network was instrumental in getting MFP passed at the federal level and helping NY to develop its initial application
ILC philosophy and MFP goal Perfect match
Services focused on helping people living independently in the community-
Core services such as benefits counseling, info & referral, housing assistance, peer counseling
Other services vary per center and communities needs – many MA funded services, OPWDD, OMH

4. Learn about deinstitutionalization in NYS.
Learning Objectives
Learn about an emerging peer support program that applies best practices in the behavioral health and Veteran’s Administration systems to nursing home transition.
Learn about deinstitutionalization in NYS.
Become familiar with the independent living philosophy.
Learn about the federal Money Follows the Person demonstration.
Attendees will learn about an emerging peer and family support program available to individuals interested in transitioning from institutional settings to community living through the federal Money Follows the Person demonstration in New York State. The Open Doors Peer Program is informed by best practices from peer services within the behavioral health system and Veterans Administration, aligned with the independent living philosophy and applied to nursing home transition. Open Doors connects paid peers and family members to individuals and their loved ones who are transitioning. Peers provide individualized, self-directed peer support and assist people in building their social capital as they return to the community.

5. Open Doors Infomercial
Developing longer videos highlighting the work and experiences of peers and recipients of peer services.

6. Money Follows the Person (MFP)
Federal demonstration:
Originated under the Deficit Reduction Act of 2005 and expanded by the Affordable Care Act.
MFP involves:
Transitioning eligible individuals from facilities to the community.
Using enhanced funding for rebalancing activities.
Eligibility:
Open Doors staff will work with you and your loved ones to determine eligibility and get you enrolled.
Must have Medicaid
At least 1 day before transition
Must reside in institution for at least 90 days
Must transition to a qualified setting
Home, apartment, or small group home with four or fewer unrelated individuals
Two components
Peer Outreach and Referral (Part A)
Transition Center (Part B)
Now called Open Doors

7. MFP Eligibility Must have Medicaid
At least 1 day before transition
Must reside in institution for at least 90 days
Must transition to a qualified setting
Home, apartment, or small group home with four or fewer unrelated individuals

8. Money Follows the Person in NYS
Two components administered by NYAIL:
Peer Outreach and Referral;
Transition Center.
Work with agency partners at the following:
NYS Department of Health (DOH);
NYS Office for People with Developmental Disabilities (OPWDD).
Olmstead Housing Subsidy (OHS) at NYAIL

9. Transition Center Project
Goal: Identify potential participants in nursing facilities, developmental centers and intermediate care facilities and facilitate successful transitions to one’s community of choice.
Transition Specialist Role:
Meet with individuals in the facility
Can also meet with family/guardian
Provide objective information about services available in the community
Help link individuals to the programs that will best meet their needs
Tell person differences in programs, what each offers, then help person decide on program that they feel provide the services that they need.
Collaboration
Create Person-Centered transition plan
Nursing Home Discharge Planners
Care Managers
Service coordinators
Resolve barriers to transition
Identification of community resources
ILC staff in all areas of state
Follow-up
Administer MFP ‘Quality of Life’ surveys after transition to assess an individual’s adjustment to the community
Every transition is like a snowflake – they are all different. Job of Transition Specialist is to find out what is getting in the way of person returning to community and figure out a way around that barrier. Common examples include finding housing, helping with benefits, working with families. Often access ILC staff such as benefits advisors, architectural modification consultants and use load closet or TRAID.

10. Peer Outreach and Referral Program
Goal: Provide one-on-one peer support to individuals and families interested in transitioning to community living.
Scope of program has been expanded to include identifying veterans in long term care facilities and connecting them with veteran peer advocates and building a statewide network of family peer advocates to support the loved ones of people transitioning.

11. Who is a peer?
Open Doors Peers are people with similar life experiences who use their shared experiences to empower people to make informed decisions about their lives. Peers are employed through their local independent living centers.
People with disabilities:
Physical and developmental disabilities;
Mental health challenges and substance use histories are included.
Veterans with disabilities.
Family members and loved ones of people with experience in institutional settings.
Experience in Long-Term Care settings preferred.
Nursing facilities, group homes, etc.
Core to IL philosophy and one of the five core IL services (just like nursing home transition).
Peers are active partners in the transition process
Peers are people with disabilities who have either lived in a nursing home/long term care facility and successfully returned to the community or someone who lives in the community and can speak to services and supports that help them remain independent.

12. Peer Training
Peers complete a mandatory eight hours of online training and complete a series of tests.
Training was informed by materials from the behavioral health, Veterans’ Administration and family support fields.
Modules include:
The Role of the Peer and the Power of Peer Support;
Strategic Sharing;
The History and Philosophy of Disability Rights and Independent Living;
Effective Communication;
Cultural, Developmental and Linguistic Competence;
Disability Literacy.
Continued learning opportunities for peers to review topical issues, provide mutual support, prevent burnout and connect them to the broader network of peers in NYS.
Peers complete a mandatory training prior to conducting outreach and providing peer services. We developed our curriculum based on over 20 years of research from best practices in peer and family support in the behavioral health, Veterans Administration systems and aligned it with Independent living philosophy.

13. Compensation
Peers are able to speak with an ILC Benefits Advisor or Division of Veterans’ Affairs (DVA) Veterans Benefits Advisor to determine how much they can make.
Each center determines peers’ rates of compensation.
Rates vary from $12 - $25 per hour;
Centers factor in lived experience, previous supervisory experience and other factors.

14. Matching Process Face sheets: Age; Disability;
Some facts about the individual;
Photo.
Effective matches = additional visits

15. We are hiring vets!

16. Workforce Readiness Training and Career Pathways for Peers
Peers gain valuable, transferable workplace experience.
For many peers, this is their first position in the workforce.
Recruiting former participants to serve as peers.
At least ten peers have transitioned into part and full-time rolls either within or outside of their ILCs.
Piloting peers as supervisors/mentors at centers
Supporting supervisors and providing technical assistance and support around working with people with physical and developmental disabilities.

17. Outreach
Peers conduct outreach to targeted Long- Term Care facilities and Community-Based Organizations to promote the program and generate referrals to Open Doors.
Utilize people’s skill sets. Some people enjoy public speaking and networking and this is the ideal role for them.
Work in coordination and collaboration with transition specialists, advocates, other ILC and community organization staff and nursing home staff.
Peers skilled at building relationships in the nursing facilities and in the communities are responsible for brining in over 200 people.
Word of mouth

18. Peers and Transition
Each meeting is individualized, goal driven and focused on skill building, developing self-help skills, learning about self-advocacy and building participants’ social capital to assist people and their loved ones live independent, self-directed lives in communities of their choice.
Peers are connectors.
Peers work as partners on the transition team to provide individualized, high quality, cost effective peer support to individuals who are interested in transitioning while empowering them to make informed decisions about their lives.
Peer services are very individualized. People work on skill building (including learning braille, putting together a resume).
Researching careers and continued learning opportunities
Peers know their communities and are able to help connect participants to community based services and supports throughout the transition process.
Accessible tech kits

19. For more information: @NYAIndependentLiving
Zach Garafalo Program Director | Money Follows the Person Peer Outreach and Referral Program New York Association on Independent Living 155 Washington Avenue | Suite 208 Albany, New York (518) | 1 (518) (fax) | Visit for more information about Open Doors and independent living in New York State.
@NYAIndependentLiving