Nursing
Facility Transitions
ALABAMA
Grant
Information
Name of Grantee
Alabama
Department of Senior Services, State Unit on Aging
Title of Grant
Nursing
Facility Transportations Program Grant
Type of Grant
Nursing
Facility Transitions, State Program
Amount of Grant
$770,000
Year Original Funding
Received
2002
Contact
Information
Caprice Chattom, Program
Coordinator
770 Washington Avenue
RSA Plaza
Suite 470
Montgomery, AL 36130
334–242–5743
cchattom@adss.state.al.us
Alan B. Stevens, Ph.D., Director
Dementia Care Research Program
UAB Gerontology and Geriatric Medicine
933 19th Street S, CH19, 218T
Birmingham, AL 35294–2041
205–934–7316
astevens@uab.edu
Subcontractor(s)
University of Alabama at Birmingham, Alabama Tombigbee Regional Commission
(ATRC) (Area Agencies on Aging [AAA])
Jefferson County Office of Senior Citizens Services (AAA)
Target
Population(s)
Persons currently enrolled in or eligible for the Alabama
Department of Senior Services (ADSS) Medicaid Waiver program who are
hospitalized and are at risk of nursing home placement, and persons recently
admitted into Medicaid-eligible nursing home residences.
Goals
- Facilitate
hospital-to-home transitions for ADSS Medicaid Waiver-eligible individuals
with dementia who wish to remain in the community by implementing the
"Hospital-to-Home" program that places ADSS Medicaid Consultants
within hospitals.
- Field test a nursing
home-to-community transition program for individuals with dementia
residing in nursing homes located in the Jefferson County
and ATRC AAA regions.
Activities
- Develop and implement
an educational program targeting Hospital Discharge Coordinators Training
will emphasize (1) the importance of making community living a viable
option for persons with dementia, (2) the unique challenges faced by
caregivers of dementia patients, (3) the resources available to
caregivers in the community, (4) basic problem solving techniques,
and (5) the role of ADSS Case Manager in assisting discharge
coordinators and family caregivers with obtaining needed resources.
- Implement a consultant
service that (1) places an ADSS Medicaid Waiver specialist within the
hospital to assist with the identification of patients with dementia who
are "at risk" of nursing home placement and (2) assist the
Hospital Discharge Planner in the development of individualized home care
plans that reduce the risk of nursing home placement.
- Inform all nursing
homes in Jefferson
County and the ATRC
region about the transition project.
- Identify resident
characteristics that would appear to predict successful community
transition.
- Implement a system for
identifying Medicaid-eligible nursing home residents who appear to be
candidates for successful transition.
- Transfer a maximum of
10 nursing home residents from each of the two AAA areas from nursing home
to home living using enhanced ADSS Medicaid Waiver services.
- Enhance ADSS Medicaid
Waiver services by implementing an extensive training system for ADSS Case
Managers in problem-solving techniques to assist them in managing the
multiple and complex demands faced by caregivers of persons with dementia
who are transitioned to the home.
- Provide additional
support services through funds initially provided by this grant, but
sustained by funding changes to the Medicaid Waiver program by the State
of Alabama.
These support services may include in-home respite services, home health
aid services, nursing home hold days, adult day care, or any other service
not currently covered by the waiver but is needed for transition back to
the community.
- Evaluate the
acceptability and feasibility of the "nursing home-to-home"
transition program.
Abstract
The ADSS proposes to collaborate with the State's 13 AAAs,
the Alabama State Nursing Home Association, the Alabama Hospital Association,
Alabama Medicaid Department, Governor's Office on Disability, the Olmstead Core
Workgroup, and the Dementia Care Research Program of the University of Alabama
at Birmingham to enhance support services provided by the Elderly and Disabled
Medicaid Waiver program to assist persons with dementia living in the community.
The project institutes a comprehensive system to support enduring changes in
the delivery of community based assistance for Medicaid eligible persons with
dementia. The project targets two populations of Medicaid eligible persons with
dementia: (1) community dwelling persons with a recent admission to the
hospital and (2) recently admitted Medicaid eligible nursing home
residents. We have chosen two AAAs because they provide both rural and urban
settings, a significant number of low-income, minority residents, and
sufficient staff capacity for program management. Our program will integrate
ADSS Medicaid Waiver services into other formal care services and into family caregiving, maximizing the benefit of both formal and
informal services available to Medicaid Waiver participants.