1. 7/1/10 PROJECT HOME

2. 7/1/10 OVERVIEW  Demonstration Project, 2005-2009  Implemented by Loretto with funding support from:  NYS DOH  Community Health Foundation of Western and Central New York

3. 7/1/10 PURPOSE  Respond to public policy and desires of an aging population to receive care in home and community based settings  Demonstrate cost savings at the local and State level  anticipated lower cost of care for individuals who use home and community based care over institutional care  Identify barriers preventing successful discharges from SNFs

4. 7/1/10 COMPONENTS  Discharge Planning  Implemented by Loretto  Workforce Development  Sub-contracted with 1199 Training and Upgrade Fund (TUF) and PHI  Evaluation (Discharge Planning)  Cornell Institute for Translational Research on Aging (CITRA)

5. 7/1/10 DISCHARGE PLANNING COMPONENT  Create an early identification and comprehensive referral and discharge planning system for hospitalized individuals identified as being in need of nursing home care  Assist area nursing homes in effective discharge planning for residents able to and desiring to live in non-institutional settings  Work with individuals whose physical or psychological health issues, housing, financial, or other needs make it challenging to create a discharge plan.

6. 7/1/10 DISCHARGE PLANNING  Plan: place 150 individuals into home and community based settings, who otherwise would likely have remained in a skilled nursing facility.  Total of 455 referrals were made  resulting in 130 enrollments  74 discharge plans were implemented

7. 7/1/10 FIELD FINDINGS  Difficulty of early identification:  Referrals: 96% from nursing homes, 4% hospitals  Original design - majority of referrals from hospitals  early identification  pro-active efforts before available resources eroded or living arrangements lost  Became impossible to secure a meaningful number of referrals from hospitals  Perhaps due to the intense pressure to discharge patients quickly once conditions stabilize

8. 7/1/10 FIELD FINDINGS  Potential for assisting younger population  Enrolled 130 of 455 referrals  Reasons for not-enrolling:  Under 65  Out of Onondaga County  Declined

9. 7/1/10 FIELD FINDINGS  Needed but not readily available services for discharge success:  case management  services that assisted with banking, grocery shopping, housekeeping, household repair, prescription coordination  subsidized housing facilities or rental assistance programs - waiting lists limited their availability

10. 7/1/10 EVALUATION  CITRA