Systems Change Grants for Community Living Compendium Third Edition South Carolina NFT 2002

2002 Nursing Facility Transitions Grants

SOUTH CAROLINA

Grant Information

Name of Grantee: Department of Health and Human Services, Office of Senior and Long-Term Care
Title of Grant: South Carolina Home Again
Type of Grant: Nursing Facility Transitions, State Program
Amount of Grant: $600,000
Year Original Funding Received: 2002

Contact Information

Kara Lewis, Project Officer
803–898–2590
lewis@dhhs.state.sc.us

Joi Martinez Goodson, Project Manager
DHHS
CLTC, 7th Floor
PO Box 8206
Columbia, SC 29202–8206
803–898–2590
goodsonj@dhhs.state.sc.us

Subcontractor(s)

None.

Target Population(s)

All populations in nursing facilities, with the exception of clients diagnosed as solely mentally retarded.

Goals

Develop community partnerships with nursing homes and advocates.
Develop targeting mechanism to identify clients and community needs.
Develop transitional service package.
Evaluate success of project and modify for post-grant ongoing efforts.

Activities

Begin dialogue with area nursing facilities to lay groundwork for successful participation.
Develop the comprehensive assessment instrument to be used in identifying and transitioning clients to the community.
Expand the dialogue with HUD and local housing authorities in the target areas and develop a housing database.
Initiate Community Transition Nursing and the bundled mental health service package.
Begin targeting potential transition clients.
Expand housing partnerships to include new HUD grant recipients for additional commitments.
Use the comprehensive assessment instrument to identify potential transition clients.
Assist a projected 20 residents with community relocation.
Implement newly developed transitional services as needed and identified in the care plan.
Conduct a year-end evaluation to determine progress and success.

Abstract

This project is directed in joint partnership with two state agencies, the SC Department of Mental Health (DMH) and the SC Department of Disabilities and Special Needs (DDSN). This grant was prepared with the objective of identifying and transitioning nursing home clients wanting to reside in the community, as well as implementing system changes needed indefinitely. The target population for this grant includes the elderly, individuals with disabilities, and clients with mental health conditions, excluding those solely diagnosed with mental retardation.

Newly hired grant staff will be primarily responsible for developing a comprehensive assessment instrument for targeting appropriate transition clients. The state intends to use the instrument with a transition team comprised of a community transition nurse (RN), the nursing facility social service worker and other nursing facility staff, the CLTC case manager (or DDSN Service Coordinator), and the client/family.

For transition clients with immediate needs, the state intends to utilize grant funds to assist with the short-term provision of rent deposits, furniture procurement, groceries, etc. Transition clients will be immediately enrolled into a waiver and then offered expanded supports. The RN will address pertinent medical issues and provide intensive caregiver/client training.

Given the intended transition of clients diagnosed with mental illness, it will be necessary to develop a package of relevant mental health services easily accessible in the community. This process will utilize supports already available and expand them in scope and frequency in recognition of transition anxiety.

Working in collaboration with the previously approved Real Choice for Systems Change grant, the nursing home transition project plans to utilize "South Carolina Access" and "South Carolina Choice." "South Carolina Access" will be a statewide information and referral system database. "South Carolina Choice" is a demonstration waiver to test an enhanced method of offering self-directed care to clients served by Community Long Term Care in the Spartanburg area. It will provide greater options with regard to the types of services and providers allowed to receive Medicaid reimbursement.