Nursing Facility Transition

These resources come from a CMS-funded pilot program where four participating quality improvement organizations (QIOs) test interventions designed to understand and change health care cost and quality patterns that differ between regions. The CARE tools ensure quality maintenance during health care transitions by assessing and recording key data. The archived weekly learning sessions cover a variety of topics related to transitional care and include handouts and audio recordings.

This issue brief reviews how new rules issued by CMS governing Medicaid coverage of targeted case management (TCM) services would affect people with complex health needs receiving home and community-based services. The author finds that the availability of several important services and strategies used in TCM would be significantly reduced. New record keeping requirements would also increase administrative burdens and costs.

HHS announced an $8.8 million investment to help states provide more affordable choices to individuals struggling to remain in their homes and communities as they age. A total of $5.7 million in federal funding was awarded to 12 states for grants for this nursing home diversion program that will improve state efforts to assist individuals avoid unnecessary nursing home placement, impoverishment and spend-down to Medicaid.

The National Health Policy Forum Issue Brief provides information about Systems Change grants and the kinds of activities state Medicaid agencies have undertaken to transform their institutionally based systems. This brief raises critical policy questions related to public spending for long-term care in different settings that might be considered in tandem with future grant funding decisions.

The Michigan Nursing Facility Transitions Initiative (NFTI) produced both a brochure and video to offer first hand accounts of their program. Meet a few of the people who the program has helped transition. View consumer stories as well as testimonials from their support specialist.

The purpose of the New York Real Choice Training Manual is to provide formal training to self-advocates who wish to become peer mentors. Mentor trainees will learn through the adult education model, which builds on the strength, capacity and experience of the learners. Self-Advocate consultants/mentors bring with them an incredible wealth of life experiences, which prepare them for this role.

This report focuses on individuals with Alzheimer's and other dementias. The project instituted a comprehensive system to support enduring changes in the delivery of community-based assistance for Medicaid eligible persons with dementia. The projects two goals: facilitate hospital-to-home transitions for individuals wishing to stay in the community; and field test a nursing home-to-community transition program for eligible individuals. The workbook used in discharge planner training is included.

This report provides an overview of 35 states’ initiatives to improve their LTC systems and includes lessons learned and recommendations that can guide states undertaking similar initiatives. Despite accomplishments and improvements, Grantees described continuing barriers including insufficient funding for home and community services; workforce shortages; lack of affordable and accessible housing and transportation; and outdated or inflexible administrative, statutory, and regulatory provisions.

Various informative documents about the Ohio Access Success Project, a grant sponsored project aimed at nursing facility transition. documents include a presentation and fact sheet for consumer on the program and a fact sheets about frequently asked questions on nursing homes.

This document summarizes the meeting on Money Follows the Person: Financing and Budgeting, convened by Rutgers Center for State Health Policy and the National Academy for State Health Policy, held on September 11-13, 2006 in Olympia, Washington. Participants discussed budgeting and financing approaches states can use to assist their residents in moving from institutions to community settings. This document will provide a brief description of the meeting and a guide to resources that were shared.