Sustainability

Michigan developed a six-part training on transition and diversion. Module 5 guides service providers through the transition periods and its follow-up. Handouts include transition planning guidelines and timelines, nursing facility transition services, and expenditure reports.

A goal of the Maryland Real Choice grant was to “provide information and assistance to consumer in acute care hospitals to aid decision-making and assist with transitions back to the community.” In 2003, a hospital discharge initiative was used to pay for nurses to work with patients being discharged from acute-care hospital stays. This paper reviews and answers whether there has been any change in discharge patterns from pilot sites to nursing homes relative to the rest of the state.

In laying the groundwork for sustainable improvements in the infrastructure for LTC policy and program implementation, Massachusetts Real Choice grantees conducted an assessment of current Service Coordination practices across State agencies. The research objective was to better understand present service coordination practices among agencies dealing with elderly and individuals with disabilities with the intention of identifying “promising practices”. This report presents the review results.

HCBS.org News CLIPS highlights the important work of Real Choice Systems Change Grantees. In this issue, we have interviewed 3 grantees (Tracy Warren from Idaho, Abby Hulme from Montana and Diane King from Colorado) to discuss the implementation of their Independence Plus Programs. Learn more about outreach and enrollment techniques, consumer involvement, on-line training tools, peer consultants, and improving emergency back up procedures.

Throughout the development process, programs must consider the steps to sustainability including people, planning and preparation, publicity/public relations, facilities, programs, policies and procedures, and persistence and positive passion. This entry includes a paper by Florene Stewart Poyadue offered to Family to Family grantees during a technical assistance call, plus the transcripts from the session where participants discussed the 7Ps of sustainability.

Family to Family Centers provide information and other supports both to family members and to professionals who serve children and youth with special health care needs. This topic paper highlights innovative strategies developed by individual Family to Family Centers to develop partnerships to expand their reach, to enhance outreach to parents, to serve a culturally diverse clientele, to help youth prepare for transition, and to ensure organizational sustainability.

The CMS Systems Change conference, Transforming Systems: Keys to Success was held April 10-12 in Baltimore. Presentations from the 2006 sessions are available in both PDF and text formats. Topics range from ideas on system transformation, stakeholder involvement, coalition building, strategic planning, sustaining systems change, and the Deficit Reduction Act. Full titles are listed in the keywords section.

The third paper in the series examines what contemporary social service systems can do to promote consumer-directed services. We identify different features that make a service \"self-directed,\" and we identify characteristics of successful consumer direction and self-determination. In its present form, this paper serves as foundation work for additional dialogue and will also undergo continuing development in discussions with representatives of projects and consumer leaders in states.

The second in the series, this paper identifies the features of high-quality integrated community services and the systems that support them and serves as the foundation work for additional exploration. The paper will undergo continuing development in discussions with representatives of projects and consumer leaders, will augment assessment of existing systems and planning of new or improved systems, and ideally become an even more useful tool for those involved in systems transformation.

First of Three Papers on Unlocking the Code of Effective Systems Change - This paper attempts to create an overall framework for the discussion of systems change and to give a summary of the concepts. Several specific recommendations from other successful programs and the recommendations and guidance of the colloquium participants, can be applied now by any grantee, state, or program to enhance prospects of achieving enduring change in home- and community-based services.