North Carolina NFT Summary | advancingstates.org

<HR ALIGN=\"left\" ALT=\"Horizontal rule dividing sections\"> <A NAME=\"NCNFT\"></A> <P ALIGN=\"RIGHT\"><EM>Nursing Facility Transitions</EM></P> <H2 ALIGN=\"CENTER\">NORTH CAROLINA</H2> <H3>Identified Problems with the State's Long-Term Care System</H3> <P> <UL> <LI>Lack of awareness about community and independent living options among consumers, their families, hospital discharge planners, nursing facility staff, and other service providers.</LI> <LI>Few state resources dedicated specifically to identifying people in nursing facilities who may be candidates for transition to a more integrated community.</LI> <LI>Few state resources dedicated specifically to providing planning and coordination services to move residents from nursing facilities to the community.</LI> <LI>Need to build stronger partnerships between the state Independent Living Rehabilitation Program (ILRP) and the Centers for Independent Living (CILs) to capitalize on their common purpose and philosophy of independent living.</LI> <LI>Service fragmentation and need for increased coordination and collaboration among agencies and organizations offering services that prevent institutionalization or that facilitate transition.</LI> <LI>Shortages of services and providers, especially in the areas of housing, transportation, and personal care workers.</LI> <LI>Fear faced by some individuals who could lose Medicaid benefits if they choose to transition from a nursing facility to community-based living.</LI> </UL> </P> <H3>Perceived Strengths</H3> <P> <UL> <LI>Independent Living System that serves individuals with disabilities in all regions of the state.</LI> <LI>A preexisting unified state vision for care systems focuses on consumers of services and on providing services in a community setting.</LI> <LI>Approved applications for Real Choice Systems Change and CPASS grants will provide access to comprehensive information on service options.</LI> <LI>The Community Alternatives Program for Disabled Adults is available statewide and is equipped to serve individuals with severe impairments.</LI> <LI>The Division of Medical Assistance is in the process of revising the nursing facility pre-admission screening and utilization review programs. These revisions will shift the focus to diverting individuals from nursing facilities.</LI> </UL> </P> <H3>Primary Focus of Grant Activities</H3> <P> <UL> <LI>Identify the needs and goals of nursing facility residents interested in transition to community.</LI> <LI>Facilitate residents' development of transition plans.</LI> <LI>Coordinate supports and services needed for successful transition.</LI> <LI>Train peer mentors to support transition candidates and help them fully reintegrate into their communities.</LI> <LI>Produce a cost-benefit analysis of <EM>Transitions</EM>, comparing the financial costs as well as individuals' quality of life and satisfaction.</LI> </UL> </P> <H3>Goals, Objectives, and Activities</H3> <P><STRONG>Overall Goal.</STRONG> Design and implement a program that will transition nursing facility residents with disabilities who wish to live outside an institutional setting, and build the infrastructure and capacity statewide to sustain the transition effort beyond the grant period.</P> <P><STRONG>Goal.</STRONG> Raise awareness among nursing facility staff, hospital discharge planners, health and human service providers, consumers and their families about community living options, the program <EM>Transitions</EM>, and how to learn more about community options in their areas.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Convene a work group of individuals to begin educating stakeholder groups about transition options.</LI> <LI>Develop educational materials targeted specifically to stakeholders. Materials will be developed with the input of the state Independent Living Rehabilitation Program (ILRP), CILs and a Participant Task Force. The materials will be targeted to consumers, nursing facility staff, hospital discharge staff, adult care home staff, family members, advocates, and other agency staff. While the materials may be slightly modified for certain groups, it is not anticipated that entirely different materials will be developed.</LI> <LI>Disseminate materials through ILRP counselors, the Transition Services Manager, CIL staff and advocates, and other partnering organizations and trained volunteers.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Determine the most effective method(s) of identifying successful candidates for community living and identify the services and supports most critical to achieving and sustaining <EM>Transitions</EM>.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Study the characteristics of residents who successfully transitioned and those who did not to determine if there are common predictors of success or failure.</LI> <LI>Analyze data on individuals who have successfully transitioned out of nursing facilities with the help of the state's CILs or ILRP as well as the nursing facility minimum data set.</LI> <LI>Test the assumption that residents with fewer disabilities and functional challenges will transition at a higher rate than those who have multiple disabilities and greater functional challenges. By tracking the characteristics of those individuals who transition, we should be able to test this assumption. However, this does not account for the "will" of the consumer, which is probably the single most important predictor of transition success.</LI> <LI>Use the nursing facility pre-admission screening program to identify individuals who may only need a short-term stay in a nursing facility.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Provide transition assistance to approximately 80 nursing facility residents in order to help them achieve their community-living goals.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Resident assessment will help identify the individual's needs and goals and will be used to help develop and plan for transition that will address those needs.</LI> <LI>Implementation of the Transition Services Fund, drawn from 100 percent grant funds, will cover transition expenses such as housing and utility deposits, household goods, and clothing.</LI> <LI>Contract with Pathways for the Future Center for Independent Living and the CyberPals program in order to supply the participants of <EM>Transitions</EM> with computers and internet access.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Strengthen the ability and capacity of the ILRP to assist nursing facility residents who choose to transition by providing more resources and services.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop and disseminate training materials, pay travel expenses for training in other communities, assist with some expenses for volunteer mentors.</LI> <LI>Project evaluators will provide ongoing feedback to ILRP about what transition methods have proved successful.</LI> <LI>Foster development of community support services by identifying gaps in needed services and by providing demand for services by moving more people into the community.</LI> <LI>Provide an impetus to consider the need for additional Medicaid services to be included in the state plan or to be made available through a new waiver program.</LI> <LI>Increase coordination among existing community services through contact with all stakeholders to avoid duplication of services and to maximize available resources. ILRP will need to improve its collaborative activities in the community in order to achieve this. Recent history has shown that ILRP has room for improvement in this area.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Evaluate the costs and benefits of transitioning to the community for nursing facility residents assisted by the <EM>Transitions</EM> program and create a plan for sustaining the program beyond the grant period.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>The evaluator will produce a report at the conclusion of the pilot phase and again before the conclusion of the 36month grant period. These reports will illustrate the strengths, weaknesses and lessons learned from the pilot sites ands suggest changes to the program.</LI> <LI>Include a cost-benefit analysis of <EM>Transitions</EM>, comparing the financial costs of nursing home care versus community care for individuals, as well as the costs and benefits to the individual's quality of life and satisfaction.</LI> <LI>Enable ILRP counselors to meet eligibility requirements for Medicaid Administrative Case management services reimbursement. This would allow additional funds to be leveraged for the counselors' transition activities, enabling ILRP to serve more individuals and freeing up the more flexible state dollars for needs not covered under other public assistance programs.</LI> </UL> </P> <H3>Key Activities and Products</H3> <P> <UL> <LI>Raise awareness among nursing facility staff, hospital discharge planners, health and human service providers, consumers and their families about community living options, <EM>Transitions</EM>, and how to learn more about community options in their areas.</LI> <LI>Determine the most effective method(s) of identifying successful candidates for community living and identify the services and supports most critical to achieving and sustaining <EM>Transitions</EM>.</LI> <LI>Provide transition assistance to approximately 80 nursing facility residents in order to help them achieve their community-living goals.</LI> <LI>Strengthen the ability and capacity of the ILRP to assist nursing facility residents who choose to transition by providing more resources and services.</LI> <LI>Evaluate the costs and benefits of transitioning to the community for nursing facility residents assisted by the <EM>Transitions</EM> program and create a plan for sustaining the program beyond the grant period.</LI> </UL> </P> <H3>Consumer Partners</H3> <P>The Participant Task Force has close to 30 members, including seven consumers, providers, advocates, and state staff. The Task Force provides input during all stages of the grant process.</P> <H3>Consumer Partners and Consumer Involvement in Planning Activities</H3> <P> <UL> <LI>The Participant Task Force guided development of all the Systems Change grants, holding three different day-long meetings during grant development. They formed a subcommittee specific to nursing facility transition to develop the NFT Grant's goals.</LI> <LI>The lead agency also solicited, via telephone and e-mail, the Participant Task Force for comments on drafts of the grant application.</LI> </UL> </P> <H3>Consumer Partners and Consumer Involvement in Implementation Activities</H3> <P> <UL> <LI>The Participant Task Force will provide consumer feedback once the program is under way, supplying valuable information that will be used in the evaluation of the <EM>Transitions</EM> program.</LI> <LI>The Task Force will participate in the development of an outreach video providing information for individuals who want to transition to the community.</LI> </UL> </P> <H3>Public Partners</H3> <P> <UL> <LI>Division of Vocational Rehabilitation's Independent Living Rehabilitation Program.</LI> <LI>Division of Aging.</LI> <LI>Division of Medical Assistance.</LI> </UL> </P> <H3>Private Partners and Subcontractors</H3> <P> <UL> <LI>Pathways for the Future Center for Independent Living.</LI> <LI>Western Alliance Centers for Independent Living, a satellite office of Pathways CIL.</LI> <LI>Citizens Together Advocacy Group, Rocky Mount.</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>The Division of Vocational Rehabilitation's ILRP has extensive experience in serving individuals with disabilities. Due to their wealth of experience and because the ILRP reaches all 100 North Carolina counties, it is a logical partner to spearhead the transition initiative across the state. ILRP counselors will educate stakeholder groups about transition options, and will provide referrals regarding potential transition candidates. These counselors will provide ongoing assistance in the transition process. The counselors will also suggest changes in the individual's plan and participate in the evaluation and integration of these changes. This group will also be involved in the discussion focusing on the "next steps" and how the gains of the program should be sustained. Generally, these counselors will act as the support system for consumers throughout the project while also providing valuable input to the project directors.</LI> <LI>Division of Vocational Rehabilitation was involved in negotiations to allow ILRP counselors to be partially reimbursed for time spent assessing, organizing and coordinating Medicaid services. This will give the ILRP additional resources to devote to working with nursing facility residents and extend the impact of the program beyond the grant period. The Division has also agreed to provide $117,000 worth of assistive technology to <EM>Transitions</EM> participants over the life of the grant.</LI> <LI>In the first year of the grant, the Asheville and Rocky Mount ILRP regional offices will pilot the program. The results of a program evaluation will be used to refine the transition model before statewide expansion of <EM>Transitions</EM> in the second and third years of the grant.</LI> <LI>Division of Aging, Assistant Secretary for Long-Term Care and Family Services has recently hired an expert whose responsibility will be to pursue housing opportunities for special needs groups. The Assistant Secretary has offered this person's expertise as a resource in helping to obtain housing for the <EM>Transitions</EM> participants and also in setting up systems to help achieve housing in the future.</LI> <LI>Division of Medical Assistance (DMA) has agreed to use Medicaid funds to support the <EM>Transitions</EM> case managers and to consider making a new waiver application targeted to meet the needs of individuals who desire to transition to the community from an institution. DMA is also developing "time-limited" prior approvals for (short-term) nursing facility care that will ensure such temporary residents get reassessed quickly for home and community-based services; the division will modify the Medicaid nursing facility prescreening tool to include modules that will assist nurse reviewers to better understand an individual's preferences for community care settings. DMA will also conduct the evaluation of the grant.</LI> </UL> </P> <P><STRONG>Private Partners</STRONG> <UL> <LI>Pathways CIL will extend its CyberPals and peer mentoring programs to participants of <EM>Transitions</EM>, and possibly even to candidates still residing in nursing facilities, so that they can begin to access a community support network.</LI> <LI>Western Alliance Center for Independent Living, Asheville will help provide individuals who transition into the community with donated computers, online support, training, and technical assistance to facilitate participation in an online community support network. They will complement ILRP services by responding to individual requests for center core services, including information and referral, advocacy, independent living skills training, peer counseling, and identification of mentors and other informal supports.</LI> <LI>Citizens Together Advocacy Group, Rocky Mount is an advocacy group for persons with disabilities is a major community partner for ILRP in the Rocky Mount area and will be active in helping identify informal community supports such as peer mentors who can provide support and encouragement to help individuals readjust to community living.</LI> </UL> </P> <P><STRONG>Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities</STRONG></P> <P>North Carolina's Division of Aging is developing coordinated information and assistance services to help reduce the fragmentation of services, which will support efforts under this grant to improve service coordination.</P> <H3>Oversight/Advisory Committee</H3> <P>This Participant Task Force will provide consumer feedback once the program is under way.</P> <H3>Formative Learning and Evaluation Activities</H3> <P> <UL> <LI>In the first year of the grant, the Asheville and Rocky Mount ILRP regional offices will pilot the program. The results of a program evaluation will be used to refine the transition model before statewide expansion of <EM>Transitions</EM> in the second and third years of the grant.</LI> <LI>The evaluators will produce a report at the conclusion of the pilot phase and again before the conclusion of the 36month grant period illustrating the strengths and weaknesses of the program, lessons learned, and possible changes to the program.</LI> <LI>The evaluation also includes a cost-benefit analysis of <EM>Transitions</EM> that compares the financial costs of nursing home care versus community-based care for individuals as well as the costs and benefits to the individual's quality of life and satisfaction. This information will be used by NC Division of Medical Assistance (Medicaid agency) for policy and planning purposes.</LI> </UL> </P> <H3>Evidence of Enduring Change/Sustainability</H3> <P> <UL> <LI>The development of training and education materials will allow consumers and their families to make informed decisions on an individual basis. These materials will be in the hands of individuals and organizations with the desire and motivation to continue to disseminate information after the grant ends. The materials will reside with ILRP after the grant, so that they can be updated as necessary.</LI> <LI>Acquired knowledge about transition, barriers, and costs and benefits will help the state fully understand what activities have the most value, and will help the state to focus on the most pressing issues in helping individuals live in the least restrictive setting.</LI> <LI>Barriers to transition documented during the grant period will likely lead to an application by DMA for a new HCBS waiver specifically targeted to meet the unique needs of individuals in institutions wishing to transition to community living.</LI> <LI>Negotiations with the Division of Vocational Rehabilitation have the potential to significantly and permanently expand ILRP's capacity to work with individuals who wish to transition from nursing facilities.</LI> </UL> </P> <H3>Geographic Focus</H3> <P>In the first year of the grant, the Asheville and Rocky Mount ILRP regional offices will pilot the program. The results of a program evaluation will be used to refine the transition model before statewide expansion of <EM>Transitions</EM> in the second and third years of the grant.</P>