Real Choice Systems Change

The goal of the QAI Datamart is to develop a consumer-based reporting and data analysis database using the Home and Community-Based Services Quality Framework. The QAI DataMart will support data analysis and decision support for quality assurance and improvement. The purpose of this Software Requirements Specification (SRS) is to document the customer’s requirements for the applications being developed or enhanced. The reports and queries available from the DataMart are also included.

One objective of the Texas’s QA/QI grant was to develop a uniform and automated critical incident reporting process. Information was collected on critical incidents reported most often by other states to be used with the Quality Assurance and Improvement (QAI) Data Mart. The QA/QI task force reviewed and used this information to develop a list of critical incident definitions and recommendations.

The Ohio Access Success project has shared various forms associated with their project aimed at nursing facility transition. The forms aid the planning and implementation of the transition process. Forms include Consumer Assessment, Referral Form, Relocation Plan and a Role Matrix.

A new database showcases the efforts of many of the TA providers serving CMS’ grantees. The database allows users to see the wide range of activities that support and enrich the grantees under the New Freedom Initiative. The database contains important information regarding existing and upcoming research products, conferences, and significant meetings as well as a wide variety of toolkits, surveys, and policy briefs, intended to be of interested to the disability and long-term care community.

Michigan developed a six-part training on transition and diversion. Module 1 is an overview of transition and diversion in the long-term care system. After a brief introduction to nursing facility transition programs, the presentation dispels some myths about the outcomes of transition and diversion programs. In addition, Module 1 discusses different aspects of nursing home transition and the legislation and lawsuits that have affected this process.

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.

These reports are reviews of Utah’s long–term care system and waiver programs and provide recommendations for change. The Focus Group Findings focused on non-institutionalized and community based settings. The Long-Term Care paper provides more generalized findings about the structure of Utah’s long-term care system and how to transition forward based on input from stakeholders and administrators, comparisons to other states, and review of current documents and policy.

MA grantees hired an independent evaluator to conduct qualitative assessments of consumers’ experiences at two and nine months of participation. At two months, the successes included connections to community supports and services. Identified challenges included developing and managing an individual budget. Successes at 9 months include increased independence, self-determination, and availability of workers and supports. Challenges included community liaison training and out-of-pocket spending.

The Consumer Planning and Implementation Group (CPIG) was formed as a way to include consumers in the Real Choice Systems Change grant activities. CPIG represents consumers across disability, age, ethnicity, geographic locations, and include community advocates/providers. CPIG provides input on grant activities and provides recommendations to the Collaborative Team (consumers and representatives for Massachusetts’ Real Choice and Independence Plus grants).