Moving Home Minnesota A New Transition Solution

1. Moving Home MinnesotaA New Transition Solution A Federal Money Follows the Person Rebalancing Demonstration June 2013

2. Agenda • Overview and background • Violet’s Story • Ellen’s Story • Summary • Question and Answer

3. Learning Objectives • After this training you will be able to describe and identify: • The goals of Moving Home Minnesota • The eligibility criteria of Moving Home Minnesota • The role of a transition coordinator • The enrollment process.

4. What is Money Follows the Person? • Federal Medicaid demonstration project • Assists individuals with transitions from nursing homes or institutions to community living • Authorized by Congress through passage of the 2005 Deficit Reduction Act • Allows states to develop, implement and evaluate demonstration and supplemental services not otherwise covered by the state’s HCBS waivers

5. What is Moving Home Minnesota? Moving Home Minnesotais the name for Minnesota’s Money Follows the Person Demonstration project

6. Goals of Moving Home Minnesota • Increase the use of home- and community-based long term care services, • Eliminate barriers that prevent or restrict flexible use of Medicaid funds for necessary long term care services in the settings reflecting individual choice, and • Increase the ability to assure continued community-based long term care services to eligible individuals after transition.

7. Mission Statement Creating choice and opportunity for Minnesotans to movefrom institutions to homes and communities, live more independently, and enhance the quality of their own lives.

8. Why Moving Home Minnesota? Honor choice Costeffective Medicaidreform Community Living Increased quality of life for participants Olmsteadplanning Systems-wide momentum Federaldemonstrationproject

9. Moving Home Minnesota and Related Initiatives • Other programs • Relocation Service Coordination • Return to Community • Housing Access Services • How Moving Home Minnesota is different: • Coordinated effort • Access to enhanced services • Potential for follow-up

10. Moving Home Minnesota Vernacular • Transition Coordinator • Demonstration Services • Supplemental Services • Person Centered Plan

11. Meet Violet

12. Individual Eligibility Requirements • All age groups • One or more qualified institutions • 90 consecutive days • Excludes Medicare rehabilitative days • Medical Assistance has paid for at least 1 day of institutional care prior to discharge. • Resident of Minnesota

13. Moving Home Minnesota Qualified Institutions • Hospitals • Nursing facilities • Intermediate Care Facilities for People with Developmental Disabilities (ICF/DD) • Institutions for people with mental diseases (participants under 21 or 65 years of age or older).

15. Qualified Community Residence • Single-family home owned or leased by the individual or the individual’s family member; • Apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing and cooking areas over which the individual or the individual’s family has domain and control; or • Residence in a community-based residential setting, in which no more than 4 unrelated individuals reside.

16. How to Access Moving Home Minnesota • Fax • 651-431-7745 • Mail • PO Box 64250 St. Paul, MN 55164-0250 • Online (available in the future) • Phone • Senior LinkAge Line® • Disability Linkage Line® • Managed Care Coordinator • Case Manager

17. Enrollment Process

19. Recruitment Strategies • Letters to potential participants • Identified through MDS/MMIS data using MFP criteria • Referrals from facilities (including Section Q) • Referrals from providers and lead agencies • Long-term care consultation

20. What is the role of a Transition Coordinator? • Someone with experience relocating people who use services. • Identified by the lead agency • Transition Coordinator is a term used by MFP programs across the country.

21. Potential Transition Coordinators • Managed Care Organization Care Coordinator • Lead agency case manager • Another professional designated by the lead agency. This professional needs to meet the minimum qualifications of an RSC

22. Transition Coordinator Responsibilities • Facilitate person centered transition planning • Understand demonstration services and other community services/supports and how to access • Collaborate with person’s existing supports

23. Transition Coordinator Responsibilities, cont. • Explore and identify housing options • Inform participant of their rights • Assist with preparation of needed documentation • Help create 24-hour emergency back-up plan

24. Communication with DHS and Transition Coordinators DHS • Receive forms • Determine eligibility based on criteria • Inform designated County/MCO contacts of eligible participants Transition Coordinators • Complete informed consent with eligible participants • Forward signed Informed Consent to DHS • Notify DHS about discharge plans and successful transitions

25. Purpose of Communication • Alert county of eligibility • Currently there is no eligibility type in MMIS for Moving Home MN • DHS must receive notification of transition date to enter into MMIS • Tracking and referral for 90 day follow up to 5 years • Tracking of housing type for enrollment changes • Demonstration requires follow up and evaluation

26. Meet Ellen

27. Olmstead: Housing as a Continuum Institutional Most restrictive Least integrated Dependent Community Least restricted Most integrated Independent GOAL Factors impacting choice • Individual-based • Preferences • Level of support needed • Resources (income and support) • Community-based • Availability of options • Availability of supports • Affordability

28. How did Ellen Move Home? • Person Centered Plan • DD waiver services • Moving Home MN Demonstration and Supplemental Services • not otherwise covered by the state’s HCBS waivers or the State Plan • Support participants in transition • Assist them in developing and maintaining stability in the community • Services work in conjunction with HCBS waivers and state plan services

29. Person Centered Plan Components • Focus: What’s important to the person? What’s important for the person to keep them healthy and safe? • Individualized • Risk Mitigation and emergency back up plan

30. Ellen’s Person Centered Plan • Strategies for managing her mood and periodic aggression • Consultation and Collaboration • 1:1 staffing in community through waiver Supportive Living Services (SLS) • Door alarm so staff/family know when leaves • YMCA membership for regular light workouts (accompanied by staff) to assist with anger management

31. Risk Assessment and Mitigation • Required components of the demonstration • Assessment of risks associated with community living for each individual • Plan to mitigate the risks • Acknowledgement of the risks and the plan by the person, planning team members and others

32. Risk Mitigation Plan Factors • Community Connectedness • Family & Friends • Leisure/Social Activities • Financial • Self-advocacy • Access • Transportation • Employment • Informal support network • Paid supporters • Health and Medical Safety • Emergency Back-up plan • Medications • Contact information • Mental Health History • Substance Abuse or Use • Critical Dependencies

33. Moving Home Minnesota Services • Can be utilized with Home and Community Based Service waivers and state plan services • Also available to those under the age of 65 in lieu of a waiver • Demonstration and supplemental services available to person for 12 months after transition

34. Demonstration and Supplemental Services for All Populations • Transition Planning and Transition Coordination Services • Comprehensive Community Support Services • Pre and Post -Discharge Case Consultation and Collaboration • Night Supervision • Environmental modifications • Personal emergency response systems • Durable Medical Equipment and Assistive technology • Non-medical transportation • Membership fees (Supplemental) • Tools, clothing and equipment (Supplemental)

35. Demonstration and Supplemental Services for Specific Populations Ages 0-21 Under Age 65 Certified Peer Specialist (CPS) Supported Employment Services • Psychoeducation Services • Respite Services • Youth Assertive Community Treatment Ages 65+ • Caregiver Education

36. Changes in Enrollment Changes in enrollment in Moving Home Minnesota can occur when: • Person leaves qualified residence • Person returns to an institution (suspension) • Demonstration period ends (12-months post-discharge) • Participants decides to end involvement

37. Re-institutionalization • Less than 30 days - Remains on Moving Home MN • More than 30 days - Moving Home MN services are suspended until the participant returns to the community

38. Follow Up and Evaluation Data from MFP states are part of a national evaluation conducted by Mathematica • Each participant will receive face-to-face surveys and follow-up by Vital Research regarding services • Prior to discharge • At 11 months, and • At 24 months • Participants will be able to receive follow up calls every 90 days for up to five years

39. Summary • Moving Home Minnesota Goals • Simplify and improve effectiveness of transition services • More consistent individualized approaches to HCBS to better serve those with complex needs • Increase stability by strengthening community connections • Decrease reliance on institutional care

40. Questions movinghomemn.mfp@state.mn.us