Delaware NFT Summary | advancingstates.org

<HR ALIGN=\"left\" ALT=\"Horizontal rule dividing sections\"> <A NAME=\"DENFTSP\"></A> <P ALIGN=\"RIGHT\"><EM>Nursing Facility Transitions</EM></P> <H2 ALIGN=\"CENTER\">DELAWARE</H2> <H3>Identified Problems with the State's Long-Term Care System</H3> <P> <UL> <LI>Numbers of residents desiring transition to the community is unknown.</LI> <LI>Public perception of transition-related issues is mixed and poorly informed.</LI> <LI>Lack of accessible, affordable housing and other community supports.</LI> <LI>Medicaid home and community-based services policies and practices are not aligned with best practices.</LI> <LI>Workforce retention is a big problem.</LI> </UL> </P> <H3>Perceived Strengths</H3> <P> <UL> <LI>Delaware maintains strong and open lines of communication among the state's legislators, meetings are easy to arrange, and state legislators are located near to their communities.</LI> <LI>The state's efforts to provide community services to elderly persons and individuals with disabilities predates the Olmstead decision (but still do not meet the needs of all persons with disabilities who would like to live in the community).</LI> <LI>A Grant Oversight Committee (GOC) has already been established and is providing guidance to project staff regarding grant activities.</LI> </UL> </P> <H3>Primary Focus of Grant Activities</H3> <P> <UL> <LI>Provide skills training and support services to transition consumers.</LI> <LI>Increase housing opportunities for community living.</LI> <LI>Locate alternative funding streams for transition-related services.</LI> <LI>Provide enhanced community support services.</LI> <LI>Address workforce recruitment and retention issues.</LI> <LI>Promote quality of services.</LI> </UL> </P> <H3>Goals, Objectives, and Activities</H3> <P><STRONG>Overall Goal.</STRONG> Develop a pilot project that will identify individuals residing within long-term care facilities that wish to move to an integrated community setting and then support them throughout the transition process and beyond.</P> <P><STRONG>Goal.</STRONG> Identify and support institutionalized individuals wishing to transition to an integrated community setting.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop a system to identify consumers who want to transition.</LI> <LI>Identify 15 consumers statewide who want to move from nursing facilities to the community and assess their support needs.</LI> <LI>Determine fiscal resources needed for transitioning.</LI> <LI>Evaluate service gaps in accessible housing, transportation, and Medicaid. "Delaware Passport to Independence" (DPI) will concentrate on the needs of the 15 consumers to be transitioned and identify the root causes of these gaps, identify and collaborate with experts in these areas to seek feasible and sustainable solutions, and will communicate with legislators that may be willing to seek changes in legislation.</LI> <LI>Identify consumer-driven case management options. The case management team will utilize a person centered approach, and the consumer will have direct participation in determining their action plans and services. Consumers will agree to share responsibility for the successful implementation of the plan.</LI> <LI>Transition identified participants to the community.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Provide skills training and education about available resources for transitioning consumers.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Convene focus groups of peers who have transitioned.</LI> <LI>Survey groups of paid personal assistance workers to assess the perceptions and barriers relating to transitioning, awareness of available resources, and to get suggestions for the project.</LI> <LI>Develop a service and supports notebook and distribute to consumers. The notebook will be a directory of services, providers, and supports that are available and accessible to the consumer in the community.</LI> <LI>Develop a transition training package for project and consumer use. The Freedom Center and the Independent Resources, Inc. (IRI) will be encouraged to teach consumer-related courses to the consumers. IRI is currently teaching nine courses. DPI will collaborate with both partners in developing curriculum.</LI> <LI>Develop a "Lifelong Transition Academy" of ongoing training and outreach programs. Freedom Center and IRI staff will be encouraged to teach consumer courses using curriculum that have been collaboratively developed. DPI and Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) staff will teach facility and discharge staff as appropriate.</LI> <LI>Establish relationships with senior centers and organizations for older people and people with disabilities to assist with identifying service gaps, consumer satisfaction and needs, and community resources.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Increase availability of appropriate housing for individuals transitioning to the community.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Identify currently available housing options and identify barriers to additional affordable, accessible housing.</LI> <LI>Define and formalize interagency partnerships between DSAAPD and local and state housing authorities to address identified barriers.</LI> <LI>Seek partnerships with professional building and housing industry organizations to address housing barriers.</LI> <LI>Increase utilization of the Delaware State Housing Authority's Housing Resource Directory within the DSAAPD and other agencies.</LI> <LI>Identify additional funding sources for housing and pursue funding from these sources.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Reduce institutionalization.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop organized educational programs to inform consumers, families and friends, and health care providers regarding community alternatives to institutional placement.</LI> <LI>Seek participation in grant activities of Delaware's Nursing Home Residence Quality Assurance Commission, Medical Society of Delaware, and local medical practitioners.</LI> <LI>Improve the awareness of local medical practitioners by speaking at the forum of local medical practitioners, and the Medical Society of Delaware, about the independent living options available in the community.</LI> <LI>Educate hospital discharge teams about home and community-based services options.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Maximize funding for service provision and locate alternative funding streams.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Change Medicaid policies and practices to reflect best practices for community services. DPI staff will contact other states with established transition programs and CMS to learn about best practices. Recognizing that there may be some services that Medicaid will not fund, DPI will seek to learn how other states are funding such services, if any.</LI> <LI>Identify service gaps in waiver programs.</LI> <LI>Apply for a new waiver to remove individual cost limits, using aggregate costs to show cost-neutrality.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Provide enhanced community support services.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop and implement a strategic plan to meet consumer needs before, during and after transition.</LI> <LI>Establish a network of trained volunteers to support consumers.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Develop and improve workforce recruitment and retention.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Identify innovative methods for recruitment and retention.</LI> <LI>Study the issues pertinent to the development of training programs and professional development programs for direct support professionals.</LI> <LI>Establish the linkages and partnerships that will provide the department with the know-how and resources to develop a workforce training program.</LI> <LI>DPI staff will train facility administrators and hospital discharge personnel as appropriate. In future, DPI hopes to influence the community college and the Center for Disability Studies at the University of Delaware, to teach courses on home and community services options.</LI> </UL> </P> <H3>Key Activities and Products</H3> <P> <UL> <LI>Develop a system to identify candidates for transitioning and transition them to the community.</LI> <LI>Develop and distribute a services and supports notebook. This will be a directory of services, providers, and supports that are available and accessible to the consumer in the community. The notebook will be distributed to hospitals, medical offices, facilities, families and guardians.</LI> <LI>Develop a transition training package in partnership with the Centers for Independent Living (CILs).</LI> <LI>Survey housing barriers; expand private and public partnership opportunities; define and formalize interagency partnerships with local and state housing authorities; locate affordable and accessible housing options; and explore alternative sources of funding for housing.</LI> <LI>Develop educational programs to inform consumers, families and friends, and health care providers regarding alternatives to institutional services.</LI> <LI>Establish a network of trained volunteers to support consumers.</LI> <LI>Identify innovative methods for recruitment and retention of personal assistance workers; develop training and professional development programs in partnership with other agencies.</LI> </UL> </P> <H3>Consumer Partners</H3> <P> <UL> <LI>The GOC includes consumer members that are affiliated with CIL and ADAPT.</LI> <LI>The State Council for Persons with Disabilities (SCPD) is a 25member council with membership across state agencies and includes 12 consumers with disabilities and two family members.</LI> </UL> </P> <H3>Consumer Partners and Consumer Involvement in Planning Activities</H3> <P>The GOC, which was established prior to receiving the grant, helped identify ways to better link programs and services to improve interagency collaboration and service delivery. They also helped to identify key stakeholders.</P> <H3>Consumer Partners and Consumer Involvement in Implementation Activities</H3> <P> <UL> <LI>The GOC will be responsible for overseeing all grant-related activities. The GOC will also have the responsibility for convening subcommittees to address specific issues pertinent to the grant.</LI> <LI>GOC will assist the DSAAPD to develop a community-based network of trained volunteers for peer support, including visitation and phone support, and a system for reporting grant progress.</LI> <LI>The SCPD will facilitate participation by the disabled community on advisory committees, assist with stakeholder meetings, and act as a liaison to the executive and legislative branches of the state government.</LI> <LI>The grantee will work closely with the CIL and the local ADAPT chapter. Staff and consumers that are affiliated with CIL and ADAPT currently serve with DPI staff on the grant's GOC, and the Housing Committee (a subcommittee of the State Council on Disabilities). The Freedom Center has been requested by DPI to conduct training sessions for DSAAPD staff and identified personnel from the community. DPI will continue to work with CIL and ADAPT to develop curriculum for consumer-related courses.</LI> <LI>The GOC will evaluate RFPs for a contractor to identify and assess nursing facility residents interested in transition, and for an independent contractor for data collection, evaluation, and final report preparation.</LI> <LI>Consumers will be part of the volunteer network to support transitioning participants.</LI> </UL> </P> <H3>Public Partners</H3> <P> <UL> <LI>Delaware State Housing Authority (DHSA).</LI> <LI>The Division of Vocational Rehabilitation (DVR).</LI> <LI>The Division of Developmental Disabilities Services (DDDS).</LI> <LI>The Division for the Visually Impaired (DVI).</LI> <LI>Division of Substance Abuse and Mental Health (DSAMH).</LI> <LI>Division of Social Services (Medicaid).</LI> </UL> </P> <H3>Private Partners and Subcontractors</H3> <P> <UL> <LI>Independent Resources, Inc. (IRI).</LI> <LI>Delaware Assistive Technology Initiative (DATI).</LI> <LI>Three to four more to be selected via RFP.</LI> </UL> </P> <H3>Public and Private Partnership Development/Involvement in the Planning Phase</H3> <P>No partners were involved.</P> <H3>Public and Private Partnership Development/Involvement in Implementation</H3> <P><STRONG>Public Partners</STRONG> <UL> <LI>Delaware State Housing Authority will pursue HUD opportunities for additional funding for affordable, accessible housing.</LI> <LI>The Division of Vocational Rehabilitation will enhance interagency collaboration. Vocational Rehabilitation staff have collaborated with DPI staff on issues that will facilitate successful transition, e.g., coordination of benefits, employment, and accessible housing. DPI staff and Vocational Rehabilitation Staff currently serve together on the GOC and the Housing Committee. Staff of both agencies continue to meet to exchange ideas on transition related issues.</LI> <LI>The Division of Developmental Disabilities Services will develop consumer training and professional development programs.</LI> <LI>The Division for the Visually Impaired will be involved with transitioning and supporting consumers in the community.</LI> <LI>A representative of the Division of Substance Abuse and Mental Health will serve on the GOC, will share housing expertise and review the continuous treatment team (CTT) approach to case management.</LI> <LI>The Division of Social Services (Medicaid) will examine Medicaid policies and practices and identify gaps in waiver services.</LI> </UL> </P> <P><STRONG>Private Partners</STRONG> <UL> <LI>IRI will provide information on accessible housing, transportation, and other community services, which will help in the activities to identify housing barriers and gaps in services.</LI> <LI>Delaware Assistive Technology Initiative has collected data as part of a study on accessible housing, which will be shared with the grant to assist its effort to identify housing barriers.</LI> <LI>Private partners were encouraged to participate in bidding for the outreach and assessment contracts of the transition program. They will also be encouraged to participate in bidding for the evaluation and case management contracts of the program. Private partners will conduct training sessions for contractors and division staff. Private partners serve on the GOC and on bid-selection committees.</LI> </UL> </P> <P><STRONG>Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities</STRONG></P> <P>Carelink, which manages the Delaware Community Access Program (a consumer-driven program providing housing, transition supports, life skills training, and independent living training to adults with physical disabilities), and the Division of Vocational Rehabilitation will lend their expertise. Carelink is already providing home and community-based services. All the grant activities will benefit from the expertise of Carelink and similar statewide organizations.</P> <H3>Oversight/Advisory Committee</H3> <P>A GOC comprising statewide representation and leadership from public agencies, private organizations, community members, and consumers, will guide all project-related activities, will ensure that information is shared among partners and stakeholders and will review project updates and reports.</P> <H3>Formative Learning and Evaluation Activities</H3> <P>During the project, GOC will determine criteria and benchmarks to evaluate the project as it continues, will meet monthly to review the contractor's report, ensure that the contractor is maintaining a project history, and submit a final report to the Governor and the DHSS.</P> <H3>Evidence of Enduring Change/Sustainability</H3> <P> <UL> <LI>The Division will update, print, and distribute the Consumer Resource Notebook, which will also be available on the Division's Website.</LI> <LI>Training programs and professional development programs will be part of our existing mission to provide community education on request. We will continue to do this not only on request, but as we recognize the need within the community. A listing of our services is available on our Website. We will continue to develop curriculum with our partner CILs and with the Freedom Center so that lifelong transition training can be offered to consumers on a consistent basis. These options will be made available to administrators, and hospital discharge personnel.</LI> <LI>Changes in Medicaid policies and practices to reflect models from other states.</LI> <LI>A network of trained volunteers to provide peer support for consumers.</LI> </UL> </P> <H3>Geographic Focus</H3> <P>Statewide.</P>