1. National Mental Health & Aging and PASRR Conference: March 24-25, 2014 Indianapolis, IN

2. Transitions result from….. Multi-pronged approaches to rebalancing Ongoing Collaboration

3. Multi Pronged Approach to Rebalancing Goal to transition individuals to least restrictive environment Mental Health Waiver/MFP Nursing Diversion and Transition Program Outreach and Engagement Project

4. Mental Health Waiver/ W.I.S.E. Program 1 of 2 MH waivers in U.S. Operational since April 2009 Assists clients to be diverted or discharged from NHs Linked to MFP Person-Centered, Recovery and Psych Rehab Model Recovery Assistant: hybrid companion, homemaker, PCA, and respite Cost Neutrality www.ct.gov/dmhas/cwp/view.asp?a=290&q=425724

5. Nursing Home Diversion & Transition Program Nurse Clinicians and Case Managers assigned to geographic locations in state Clarify/validate Level of Care (LOC) needs and services Cross-trained with Mental Health Waiver program Monthly meetings with NH staff and Money Follows the Person (MFP) staff Piloting groups in NH settings: Chronic disease self management Double Trouble for co-occurring Mental Illness & Substance Abuse Community skills-building

6. Outreach and Engagement Project Outreach to residents in nursing facilities Education to nursing facilities, home care agencies, behavioral health providers, community resources Ongoing engagement of residents Shifting Culture Institution vs. Home Based Care Providers and Residents experience change

7. Collaboration through….. Keeping the conversation going & shared responsibility. Public/Private input to Core Standardized Assessment Tool. Consultation between waiver programs. Cross-agency/provider trainings and retreats. PASRR process & follow-up on Level II recommendations. MDS Section Q prompts NH to refer to MFP

8. State of CT Overview Statewide Services Unit & PASRR Key Offices MFP Alternate Care Unit Other waiver units EPS PASRR and Electronic Vendor Medicaid Authority MH Authority State DD Authority ADRCs State Dept. Public Health State Dept. on Aging Triple A’s LTC Ombudsman’s Office Nursing Homes Hospitals Independent Living Centers Community providers Others Community Placements NHDTP MH Waiver (W.I.S.E.) Outreach and Engagement

9. Give a Hoot Don’t Institute!! Jennifer Glick, RN, MSW, 860-262-5818 jennifer.glick@ct.govjennifer.glick@ct.gov Megan Goodfield, LCSW, 860-262-6953 megan.goodfield@ct.govmegan.goodfield@ct.gov CT Department of Mental Health & Addiction Services www.ct.gov/dmhas