Nursing Facility Transitions

OHIO

Grant Information

Name of Grantee

Ohio Department of Job and Family Services

Title of Grant

Ohio Access Success Project

Type of Grant

Nursing Facility Transitions, State Program

Amount of Grant

$600,000

Year Original Funding Received

2002

Expected Completion Date

September 2006

Contact Information

Laurie Damon, Project Manager
Ohio Department of Job and Family Services
Bureau of Home and Community Services
30 E. Broad Street, 33rd Floor
Columbus, OH 43215-3414
614-644-1820
mailto:damonl@odjfs.state.oh.us

Subcontractor(s)

Easter Seals of Central and Southeast Ohio

Target Population(s)

Identified adult nursing home residents who desire to move from the nursing home to a community–based setting.

Goals

  • Develop a transition protocol that addresses factors necessary for the successful transition of an individual consumer residing in a nursing facility to a community-based setting, while being responsive to consumer choice and control.
  • Transition 100 consumers from nursing homes to community-based settings over the duration of the grant period.
  • Identify resources and establish linkages in community settings that can be integrated into the current infrastructure and that will facilitate the transition of consumers to the community.

Activities

  • With input from the Ohio Olmstead Task Force and the assistance of a stakeholder work group, develop a transition protocol to identify nursing facility residents who want to and are good candidates to move from a nursing home to a community-based setting.
  • Provide information about the transition program to targeted stakeholder groups to increase their awareness of the transition program and develop referral sources.
  • Provide information about the transition program to residents of nursing homes to allow them to make informed choices about their interest and participation in the transition program.
  • Work with eligible nursing home residents wishing to transition from a nursing home to a community setting to assess what their needs (both medical and psychosocial) will be in a community setting, develop a relocation and follow-up plan, provide assistance with transportation and housing, as well as application for enrollment onto home and community based waivers, if that will be needed.
  • Incorporate peer coaches into the transition program to assist consumers in the transition process.
  • As a component of the transition program, conduct four follow-up visits with relocated consumers in the first year after the individual has moved to the community to ascertain the consumer's overall satisfaction with the new living arrangement, measure the progress in the individual's transition plan, and obtain participant suggestions for improving the transition process.
  • Fund a housing coordinator who provides assistance to the transition teams in finding appropriate housing for participating consumers.
  • Utilize allocated state funds for participating consumers' relocation expenses.
  • Evaluate the services provided to participating consumers to identify changes needed in the transition program and follow-up feedback to the contract manager and members of the Consumer Task Force.
  • Identify and build a base of resource information that will support people moving from a nursing home to a community-based setting on an ongoing basis, particularly in the area of housing.
  • Provide results of an evaluation to the State and to key stakeholders, including the Olmstead Consumer Task Force.

Abstract

The "Ohio Access Success Project" has created a coordinated nursing facility transition protocol to identify and support the successful relocation to community-based settings of 100 consumers living in nursing homes. The protocol incorporates an interdisciplinary team consisting of a social worker, nurse, and peer coach. A housing coordinator is available to relocation teams for consultation and to provide assistance to the transition teams in finding appropriate housing for participating consumers.

Consumers who have relocated to a community-based setting receive follow-up visits from the relocation team to assess their satisfaction with the relocation protocols and their continued well-being after their relocation. Feedback on this will be provided to the State, to members of the project's stakeholder work group, and to the Ohio Olmstead Task Force.

As Ohio works through the process of transitioning nursing home residents back to a community-based setting, resources and linkages in a community that assist in a consumer's successful transition are being identified with the goal of developing similar resources and linkages in other communities. Barriers to a consumer's successful transition are also being identified.

The program will be evaluated by the contractor. It is hoped that Ohio will be able to sustain a nursing facility transition program after the end of the grant period.