Massachusetts “Bridges” to Community

Agenda

Project OverviewWho is eligible?What is the processQuestions & Feedback

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.

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

Nursing Facility Transitions GrantThe “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

“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.

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

BridgesProject

Director

Local Housing Auth.,

Realtors, Landlordse

tc.

CMS Nursing Facility Transitions Grant

Massachusetts Bridges to Community Project

Interagency Steering

Committee

Planning and Coordinating

Group

Grant Manager

Project Director

Case Manger/Service

CoordinatorNurse Consultant

Housing ConsultantAdministrative

Assistant

Project Advisory Board

Community

Based Supports

Peer Mentors

State Housing Agencies

DMR Housing Director

Family & Friends

Community at Large

Faith

Medical Services

Vocation/ Avocation

Advocacy

Transportation

HousingLeisure

Elder Services

Social Services

Community Long Term Care

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

The Bridges Team

“Bridges” core team:• Project Director

• Case Manager

• Service Coordinator

• Nursing Consultant

• Housing Specialists

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.

Activities & Timelines

Year 1Year 1Year 1Year 1Year 2Year 2Year 2Year 2

Year 3Year 3Year 3Year 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

Examples of success in other States

Accessible, Quality Personal CareIntegrated Referrals: NF,

Hospital, CommunityAssistance with Transition CostsFinancial Incentives for

Community CareHelp NF’s Develop Community

ServicesComprehensive Housing

Development

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

Identifying Participants

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

Identifying ParticipantsWho 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.

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

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

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…

ProcessIndividual 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