Rebalancing Initiative (REBAL)

NORTH CAROLINA

Target Population

Medicaid-eligible adults with significant physical disabilities who have applied for admission, are waiting to enter, or reside in institutions such as nursing homes.

Geographic Focus

Pilot testing in two counties in Year 2, then development of a statewide implementation plan during Year 3.

Primary Focus

Reserve Home and Community Care Block Grant slots for use by persons at risk for institutionalization (or persons recently institutionalized) to prevent and correct inappropriate placements among adults with significant physical disabilities. Project staff will educate placement workers on ways of helping persons with disabilities and illnesses (and their decision makers) to consider remaining in the community and to obtain necessary community/family supports, identify supports for transition for persons already institutionalized, and employ quality management mechanisms during the pilot testing of the Rebalancing Plan to assure that diversion and transition procedures and processes are adequate.

Goals, Objectives, and Activities

Goal: Develop a targeted Rebalancing Plan to prevent and correct inappropriate placements of adults with significant physical disabilities in institutions such as nursing facilities.

Objectives/Activities

• Develop profiles of the types of people with significant physical disabilities (at risk) for whom institutionalization has been reversed.
• Identify settings (e.g., hospitals) in which rebalancing activities can occur.
• Identify rebalancing strategies that are most effective for people with significant physical disabilities.
• Identify administrative and programmatic policy and procedural changes required to implement the selected rebalancing strategies.
• Update key stakeholders (placement staff, agency directors, professional organizations, etc.) for whom orientation/training will be needed.
• Write a working draft of the Rebalancing Plan.

Goal: Test and revise the Rebalancing Plan.

Objectives/Activities

• Prepare pilot test implementation plan in two counties.
• Orient and train front line staff.
• Conduct a rebalancing pilot study with people with significant physical disabilities and their families.
• Conduct Quality Management activities to monitor participants and interview placement workers about their experiences.
• Finalize and disseminate the Rebalancing Plan.

Goal: Write and publicize an implementation plan.

Objectives/Activities

• Prepare a 5–year schedule for implementation statewide.
• Finalize, present, and approve the implementation plan.

Key Activities and Products

• Develop profiles of the types of people with significant physical disabilities (at risk) for whom institutionalization has been reversed.
• Identify rebalancing strategies that would be most effective for the targeted population.
• Identify administrative and programmatic policy and procedural changes required to implement the selected rebalancing strategies.
• Conduct a rebalancing pilot study with people with significant physical disabilities and their families.
• Conduct Quality Management activities to monitor participants and interview placement workers about their experiences.
• Finalize and disseminate the Rebalancing Plan.
• Prepare a 5–year statewide implementation plan.

Consumer Partners and their Involvement in Implementation Activities

Consumers will serve on a broadly based Rebalancing Team and will work closely with project staff in developing the Rebalancing Plan and implementation plan. Strategies for implementation include helping family members provide support; respite for caregivers; and local faith communities and voluntary organizations providing physical, social, and other supports for targeted clients.

Public and Private Partners and their Involvement in Implementation Activities

• The Department of Health and Human Services (DHHS) Long-Term Care Cabinet, consisting of DHHS Division Directors with long-term care (LTC) responsibilities, will review all new and modified processes/structures and make recommendations.
• The Rebalancing Team will include membership from relevant DHHS services (independent living, adult placement, caregiving, legal, policy development, Medicaid Statistical Information System, program planning and evaluation, guardianship, and adult protective services) as well as members of professional and consumer organizations (hospitals, Area Agencies on Aging, social workers, nursing homes, and home and community service providers). The principal DHHS agencies that will serve in an advisory role in support of the Division of Vocational Rehabilitation include the Division of Aging and Adult Services; the Division of Medical Assistance; and the Office of Research, Demonstrations and Rural Health Development, which oversees the Medicaid managed care program.
• Aging and Disability Resource Centers will participate in field testing by helping to identify and clarify long-term care issues for people with significant physical disabilities.
• The University of North Carolina (UNC) Institute on Aging will perform the process and outcome evaluations, as well as develop tools for determining what people with significant physical disabilities need to live successfully in the community.
• Subcontractors will conduct and evaluate the pilot testing of the Rebalancing Plan and conduct process and outcome evaluations.

Advisory Body, Committee, or Task Force

DHHS Long Term Care Cabinet, headed by the DHHS Assistant Secretary for Long-Term Care and Family Services, and a broadly based Rebalancing Team consisting of consumers, State agency representatives, and service providers will oversee and manage the grant project.

Formative/Process Evaluation Activities

The UNC Institute on Aging will conduct a process evaluation to examine the adequacy of the policies and procedures utilized in the pilot test. This could further include the degree to which procedures work, follow-up of targeted clients, feedback from placement workers, and feedback from clients and their families.

Summative/Outcome Evaluation Activities

The UNC Institute on Aging will conduct an outcome evaluation to measure the degree to which Medicaid-eligible adults with significant physical disabilities who are waiting to enter, are at risk of entering, or have already entered nursing homes remain in their communities. Costs of community placements versus institutional placements will also be measured.

Strategies to Ensure Sustainability

DHHS is committed to change its policies and procedures during the 3–year developmental and testing period. The key DHHS members of the Rebalancing Team will continue to exercise the responsibilities necessary to maintain the initiative, which they will acquire over the course of the 3–year period. No new monies will be needed.