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.