Nursing
Facility Transitions
NORTH CAROLINA
Grant
Information
Name of Grantee
North
Carolina Department of Health and Human Services
Title of Grant
Transitions
Type of Grant
Nursing
Facility Transitions, State Program
Amount of Grant
$600,000
Year Original Funding
Received
2002
Expected Completion Date
March
2006
Contact
Information
Lynne Perrin, Section Chief
919-857-4047
Lynne.Perrin@ncmail.net
Larry Nason
Contract Manager/Evaluator
Health Policy Analyst
Facility and Community Care Section
2501 Mail Service Center
Raleigh, NC 27699-2501
919-857-4221
Larry.Nason@ncmail.net
Subcontractor(s)
Linda Kendall, Program Director
L.H. Kendall Consulting Services
PO Box 28814
Asheville, NC 28814
828-712-4003
lkfields@mindspring.com
Target
Population(s)
Adults with disabilities who are residents of North Carolina nursing
facilities who wish to move back into the community.
Goals
- Design and implement a
program that supports transition assessment and assistance for individuals
in nursing facilities who are Medicaid-eligible or who will be
Medicaid-eligible within 6 months who wish to return to their communities.
- Build the infrastructure
and capacity to sustain the transition effort beyond the grant period for
current residents of nursing facilities who have the desire and the
capacity to transition with support services of their own.
- Work in conjunction with
the other Systems Change Grant efforts to provide a continuum of services
for people with disabilities who wish to reside in the community.
Activities
- Raise awareness among
nursing facility staff, hospital discharge planners, health and human
service providers, as well as consumers and their families about community
living options, the grant project Transitions, and how to learn
more about community options in their areas.
- Determine the most
effective method(s) of identifying successful candidates for community
living and identify the services and supports most critical to achieving
and sustaining Transitions.
- Provide transition
assistance to approximately 80 nursing facility residents in order to help
them achieve their community-living goals.
- Strengthen the ability
and capacity of the Independent Living Rehabilitation Program (ILRP) to
assist nursing facility residents who choose to transition by providing
more resources and services.
- Evaluate the costs and
benefits of transitioning to the community for nursing facility residents
assisted by the Transitions program and create a plan for
sustaining the program beyond the grant period.
Abstract
The NC Division of Medical Assistance's primary partners in this program are the Division of
Vocational Rehabilitation's statewide ILRP and Centers for Independent Living (CILs). The program, called Transitions, will utilize
the experience of ILRP and CIL Counselors/Service Coordinators to help identify
the needs and goals of nursing facility residents interested in transitioning
to community living, facilitate residents' development of transition plans, and
coordinate supports and services needed for successful transition. Pathways CIL
and its fully functional satellite office, Western Alliance CIL, will train
peer mentors in western service areas to support transition candidates and help
them fully reintegrate into their communities.
In the first year of the grant, the Asheville and Rocky Mount ILRP regional
offices will pilot the program. The results of a program evaluation will be
used to refine the transition model before statewide expansion of Transitions
in the second and third years of the grant. The success of Transitions,
however, will be highly dependent upon active community partners. Examples of
partners who have committed to be active participants in the pilot areas
include
- Western
Alliance Center
for Independent Living, Asheville.
Western Alliance will help provide
individuals who transition into the community with donated computers,
online support, training, and technical assistance to facilitate
participation in an online community support network. They will complement
ILRP services by responding to individual requests for center core
services including information and referral, advocacy, independent living
skills training, peer counseling, and identification of mentors and other
informal supports.
- Citizens Together
Advocacy Group, Rocky Mount.
This advocacy group for persons with disabilities is a major community
partner for ILRP in the Rocky
Mount area and will be active in helping identify
informal community supports, such as peer mentors, who can provide support
and encouragement to help individuals readjust to community living.
Grant funding will pay for program staff and evaluation.
More importantly, however, grant funds will be used for transition expenses not
normally covered by public assistance programs such as utility deposits,
furniture, household goods, and clothing. Grant funds will be also used to
develop and distribute educational materials about community services and
supports and provide CEU training to nursing facility staff about Transitions
and community resources.