All States/Territories

Consumer advocates and state leaders have been exploring ways to identify nursing home residents who want to return to their homes and communities. One effort involves the potential use of the Long Term Care Minimum Data Set (MDS), particularly Section Q, which addresses residents’ discharge preference. This technical assistance document provides practical information about how state agencies can use these federal data on nursing home residents to improve their nursing home transition efforts.

States face significant obstacles in diverting individuals from institutional settings. Throughout the long-term care system, there exists an institutional bias for placing people in institutional settings over HCBS settings. Most states have some form of nursing home diversion program however, these programs face several challenges. This paper outlines many of the challenges, details strategies, and offers resources.

This presentation gives a summary of the ADRC grants, common elements of early successes, key considerations for a multi-agency approach, and materials to share. Lisa Alecxih and Sharon Zeruld of The Lewin Group gave this presentation to North Carolina's ADRC Advisory Board in February 2005.

A number of states have developed rental housing locators that allow online searches for affordable housing units. These sites range from bare-bones databases of state-financed developments to elaborate sites with multiple search criteria, extensive information about accessibility for persons with disabilities, current vacancy information, and links to local service agencies. This report reviews several web-based sites based on several factors and compares the findings.

The Ticket to Work and Self-Sufficiency Program is an employment program for people with disabilities who are interested in going to work. The quarterly newsletter covers marketplace news, opportunities and experiences. This Winter 2005 issues details a new EN Promising Practices Anthology and spotlights a South Florida program. The Newsletter also has an events calendar and a list of Recently Approved Employment Network Providers.

This is the first in a series of papers synthesizing the ideas and practices of states as they improve the quality of home and community based services (HCBS) and supports for older persons and persons with disabilities. Building on the experiences and challenges of the QA/QI Systems Change grantees, the paper addresses four fundamental questions about quality management. The intent is to provide an account of current practice, and a structure for how states view their options.

Washington developed this protocol for use when the recommended plan of care can not assure the health and welfare of recipients due to participant issues, environment, or resources. Addresses shared responsibility for participant safety. Addresses service denial and service termination. The purpose is to promote statewide consistency in dealing with difficult to serve clients before denying or terminating services.

Washington has developed protocols in some high risk areas, such as skin breakdown. Protocols are automatically triggered when certain characteristics are identified in the assessment (a pressure sore or history of pressure sore, incontinence with cognitive impairment, etc.). The protocols dictates referral and recommendations for caregiver follow up.

Washington’s automated, comprehensive, person centered assessment and planning tool measures the personal care needs of anyone receiving services at home or in a residential setting and develops a care plan. The tool contains 60 different screens, some relate to risk. Participant selects a service setting and then the program computes eligibility, need and a service plan that crosses settings. The package contains: CARES Training Manual, CARES Assessment, Eligibility & Rates for LTC Services.

Developed by Oregon’s Office of Home & Community these tools include consideration of 43 areas of risk and illustrates the state’s risk tracking documentation in Q&A format. They also provide instruction to staff with loops back to participant preference and guidance to protocols to address identified risks. Forms included: ISP Addendum, Financial & Individual Support Plan, Personal Focus Worksheet, Risk Training, Protocol for Aspiration, Constipation, Dehydration, Seizure and Signature Sheet.