WEST VIRGINIA

Grant Information


Name of Grantee
Department of Health and Human Resources
Title of Grant
Transitioning to Inclusive Communities (TIC)
Type of Grant
Nursing Facility Transitions, State Program
Amount of Grant
$551,678
Year Original Funding Received
2001

Contact Information


Julie Shelton, Principle Investigator
Office of Behavioral Long–Term and Alternative Health Care
350 Capitol Street, Room 251
Charleston, WV 25301–3706
304–558–1448
julieshelton@wvdhhr.org
www.ced.wvu.edu/TIC

Subcontractor(s)

Center for Excellence in Disabilities West Virginia University
Sally Burchfiel
304–293–4692

Target Population(s)


Individuals of all ages with disabilities or long–term illness who reside in nursing facilities and/or segregated settings or are at risk of segregated placements.

Goals


  • Increase information on community resources, supports, and services to enhance informed choices for community living for persons with disabilities or those with long–term care needs.
  • Identify persons who wish to transition from nursing facilities into communities and identify necessary services and supports.
  • Develop systems of peer supports and services to improve the transition process to inclusive communities.
  • Identify barriers in Medicaid/Medicare service plans and waiver programs and recommend changes to support community living.
  • Implement transitional support models and evaluate cost effectiveness and consumer satisfaction.

Activities


  • Identify persons wanting to transition by developing informational and educational programs that provide guidance and build advocacy and self–determination skills for consumers, family members, and service providers.
  • Develop a Consumer Oversight Commission that participates in grant activities, as well as a process to increase community supports in areas such as housing, education, attendant services, and in–home health care.
  • Utilize, evaluate, and modify the Life Choices Assessment tool by conducting over 100 assessments and Person–Centered Planning for those interested in transitioning to the community or avoiding placement in nursing facilities.
  • Develop and coordinate training for the development of Transition Support Teams statewide.
  • Create a person–centered planning discharge and referral instrument that provides community options and resources and develops a data base that can be used to determine community service and support needs.

Abstract


The Transitioning to Inclusive Communities (TIC) Project will enable individuals who reside in nursing facilities or other segregated environments, or who are at risk of moving to such facilities, to transition to community residences. This goal will be accomplished through a number of activities. We will provide information resources for people with disabilities or long–term illnesses and their families, including a toll–free phone line, a web site, training, and a public awareness multimedia campaign. This information will assist the individuals considering transition to make informed choices regarding community living options.

We will identify individuals interested in transition through responses to disseminated information and training, as well as through a person–centered Life Choices Assessment Tool, used for both transitioning from and avoiding nursing or congregate facilities. Self–determination and self–advocacy skills will be enhanced through collaborations with advocacy organizations and statewide training. Community transition options will be increased through contracts with advocacy and consumer support groups to provide model peer supports and "trial" community transition choice options.

Discharge planning and intake will be augmented with a person–centered system of supports. A Transition Support Team will be modeled at nursing and congregate settings as well as with rehabilitation hospital discharge and nursing home intake personnel. This interdisciplinary support team is made up of the individual transitioning, professionals, family and friends, community members, and volunteers. Technical assistance will be provided so that a selected number of individuals can develop their own consumer–directed Transition Support Team.

Finally, the TIC Project will build additional community supports through funding nonprofit advocacy, consumer or community groups to demonstrate the use of peer supports and services in the transitioning and diversion processes. Small amounts of additional funds will demonstrate the importance of assistive technology or home start–up funds as people transition.

Consumer direction and evaluation for the TIC Project is provided through a 25–member Consumer Oversight Commission, through ongoing follow–up, and through a consumer satisfaction survey in the last year of the grant.

 

 

 

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