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Massachusetts “Bridges” to Community

Massachusetts “Bridges” to Community. Agenda. Project Overview Who is eligible? What is the process Questions & Feedback. Project Overview. What is Mass “Bridges” to Community Project?

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Massachusetts “Bridges” to Community

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

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

  9. Community Long Term Care Housing Leisure Faith Elder Services Community at Large Family & Friends Advocacy Social Services Board Members Relationship Vocation/ Avocation Transportation Medical Services

  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. 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 • Hire Staff • Identify Stakeholders • Obtain Space • Begin Outreach: • NF’s • CIL’s • MASS • Ombudsmen • Social Services • Local Community Activities & Timelines Year 1 Year 2 Year 3

  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. Identifying Participants 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

  17. Identifying Participants • 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 Lack of Community Resources Loss of Income Unaware of Available Community Resources Low Expectations Fear of the Unknown Lack of Personal Supports

  21. Bridges will provide… • 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.)

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

  23. Questions & Feedback ?

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