Nursing Facility Transitions

DELAWARE

Grant Information

Name of Grantee

Delaware Health and Social Services, Division of Services for Aging and Adults with Physical Disabilities

Title of Grant

Delaware Passport to Independence Initiative

Type of Grant

Nursing Facility Transitions, State Program

Amount of Grant

$566,772

Year Original Funding Received

2002

Contact Information

Victor Orija, Project Manager
302–255–9377
victor.orija@state.de.us

Alan Zaback, Division Director
Administrative Building, First Floor Annex
1901 N DuPont Highway
New Castle, DE 19720
302–255–9351
allan.zaback@state.de.us

Subcontractor(s)

None.

Target Population(s)

Medicaid nursing home eligible adults.

Goals

  • Identify consumers wanting to participate in transitioning and assess levels of needed supports.
  • Provide skills training and resource awareness for transitioning consumers and outreach; identify support services for consumers to utilize after transitioning.
  • Increase housing opportunities for community living.
  • Reduce institutionalization among persons with disabilities.
  • Locate alternative funding streams.
  • Provide enhanced community support services.
  • Develop and improve workforce recruitment and retention.
  • Promote quality enhancement of services delivered.

Activities

  • Develop a system to identify candidates for transitioning; determine fiscal resources to transition 15 consumers; evaluate service gaps; identify consumer-driven case management options; and transition interested consumers to the community.
  • Develop a resource notebook and identify ways to distribute it to consumers and develop a transition training package in partnership with the Centers for Independent Living.
  • 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.
  • Develop educational programs to guide system decision making; seek participation of the DE Association of Health Care Facilities and local medical practitioners; and educate hospital discharge teams.
  • Align Medicaid policies and practices with best practices for community services; and identify gaps in waiver programs.
  • Develop and implement a strategic plan to meet consumer needs before, during, and after the project, and establish a network of trained volunteers to support consumers.
  • Identify innovative methods for recruitment and retention of personal assistance workers, and develop training and professional development programs in partnership with other agencies.
  • Issue a request for proposals (RFP) to solicit an independent contractor for data collection, evaluation, and final report preparation, and develop a project evaluation tool.

Abstract

This project will identify individuals within long-term care facilities wishing to transition to an integrated community setting and select an initial group of 15 participants. During the assessment and identification process, statewide outreach to educate professional staff and the public about the Initiative and transition-related issues will be implemented. Ongoing training topics will include areas to lay the philosophical foundation for self-determination, independent living, and personal decision making within a person-centered model. Ongoing project data collection and input from stakeholders will provide the foundation for the evaluation process to monitor program effectiveness, allow for flexibility and change, and contribute to lasting improvements of service provision and support. A multidisciplinary interagency Grant Oversight Committee (GOC) will guide all project related activities, information sharing, project updates, and reports to their agency. Critical issues to be examined are the following: affordable and accessible housing availability, transition-related policies and regulations, support services, training, outreach, and sustainability. DSAAPD will coordinate activities with other agencies with Systems Change funding and welcomes the opportunity to interface common efforts, goals, strategies, and partnerships to increase access to services with a continuum of supports.