1. Massachusetts “Bridges” to Community

2. Agenda  Project Overview  Who is eligible?  What is the process  Questions & Feedback

3. Project Overview  What is Mass “Bridges” to Community Project?  Many people living in nursing homes do not know of the available alternatives, services and supports to live independently in the community.  “Bridges” is a federally funded project that helps assist people in nursing homes get the supports they need.

4. Systems Change for Community Living Grants  Four Types Nursing Facility Transitions Grant Real Choice Systems Change Community Integrated Personal Assistance Services and Supports National Technical Assistance Exchange for Community Living  In 2001 $64 Million was awarded to 37 states and 1 territory by U.S. Centers for Medicare and Medicaid Services

5. Nursing Facility Transitions Grant  The “Bridges” Project was awarded $770,000 for 3 years  Cross-agency, cross-disability project Executive Office of Health & Human Services, Executive Office of Administration and Finance (DHCD, MassHousing, CEDAC), Executive Office of Elder Affairs, Department of Mental Retardation, Massachusetts Rehabilitation Commission, Division of Medical Assistance, Department of Public Health, Department of Mental Health  Department of Mental Retardation is grantee

6. “Bridges” Project Goals  Assist eligible individuals to transition from nursing homes to community living  Identify and address service gaps, barriers and challenges facing individuals in their move to community living and their success in remaining in the community.

7. Massachusetts Bridges to Community Project Bridges Planning Group Grant Manager Bridges Case Manger Service Coordinator Nurse Consultant Housing Consultant Administrative Assistant Project Advisory Board Community Supports Peer Mentors State Housing Agencies DMR Housing Director Real Choices Leadership Team Interagency Steering Committee Olmstead, ECBS, CMS Grants Bridges Project Director Local Housing Auth., Realtors, Landlordse tc.

8. CMS Nursing Facility Transitions Grant Massachusetts Bridges to Community Project Interagency Steering Committee Planning and Coordinating Group Grant Manager Project Director Case Manger/Service Coordinator Nurse Consultant Housing Consultant Administrative Assistant Project Advisor y Board Commu nity Based Supports Peer Mentors State Housing Agencies DMR Housing Director

9. Family & Friends Commun ity at Large Faith Medical Services Vocation/ Avocation Advoc acy Transportation Housing Leisure Elder Services Social Services Community Long Term Care

10. Massachusetts Nursing Homes  Massachusetts has a total of 502 Nursing homes serving 54,000 individuals  There are 26 Nursing homes in the Worcester area serving about 2,800 individuals  “Bridges” plans to contact approximately 300 individuals These individuals are determined to need less than 110 minutes per day of skilled nursing care

11. The Bridges Team  “Bridges” core team: Project Director Case Manager Service Coordinator Nursing Consultant Housing Specialists

12. Bridges Team Responsibilities  Introduce project and explore options with nursing home residents  Develop individual plan with interested Eligible individuals Identify available community services & supports  Work with individual to implement plan Work with individuals to find a home, arrange services, and develop supports and connections.

13. Activities & Timelines Year 1 Year 1 Year 2 Year 2 Year 3 Year 3 Hire Staff Identify Stakeholders Obtain Space Begin Outreach: NF’s CIL’s MASS Ombudsmen Social Services Local Community Identify & enroll participants Transition Individuals Establish Advisory Board Peer Mentoring & Community Connections Collect/review data Share findings w/steering group Identify & enroll participants Collect/review data Share findings w/steering group Evaluate Project

14. Examples of success in other States  Accessible, Quality Personal Care  Integrated Referrals: NF, Hospital, Community  Assistance with Transition Costs  Financial Incentives for Community Care  Help NF’s Develop Community Services  Comprehensive Housing Development

15. Identifying Participants

16. Who is Eligible?  Persons Who…. Live in a nursing home in or around Worcester Are MassHealth eligible Need approximately 110 minutes or less per day of skilled assistance Express desire to live in community Identifying Participants

17.  In our experience, there are two people in nursing homes to ask about a person returning to the community: Consumer Key Nursing Home Staff

18. Identifying Participants Who better to ask?  Consumer most often knows exactly what services and how much of each the require and can tell a care provider how they want it done.

19. Identifying Participants  Key Nursing Home Staff May know the resident(s) who want to leave May be able to coordinate transitioning services from nursing home end May be knowledgeable of family and can advocate on consumer’s behalf Have knowledge important to planning supports

20. Barriers to Community Transition Fear of the Unknown Lack of Personal Supports Low Expectations Loss of Income Unaware of Available Community Resources Lack of Community Resources

21.  Case Management (someone to help with planning your transition)  Help with securing available resources (personal care, health care, money saving options)  Help with arranging housing (assist with finding accessible affordable housing, arranging utilities)  Peer counseling and mentoring (someone to talk to who has already moved back to the community)  Community connections (contacts at local churches, clubs, businesses, health services)  Transitional supports (help with getting basic furniture, adaptive equipment, security deposits for utilities and rent, etc.) Bridges will provide…

22. Process Individual Meeting with Project Staff Exploring your options (looking at housing, talking to mentors) Meetings with others of your choice Describing your preferences and needed supports Developing your transition plan Making it happen