Stan’s Path Out of an Institution
November 2013
This brief was prepared by the Coordinating Center as part of the Housing Capacity Building Initiative for
Community Living Project, a collaboration of the Departments of Housing and Urban Development (HUD) and
Health and Human Services (HHS), under the Centers for Medicare & Medicaid Services (CMS) Money Follows the
Person (MFP) Rebalancing Demonstration, CMS Contract Number GS-00F-0083N. To learn more about the
initiative visit: http://www.neweditions.net/housing/index.asp
Service Action Steps and
Housing Action Steps
Stan, a 77 year old recipient of Social Security and
Medicare, was hospitalized for 5 days after falling
and fracturing his hip. Stan was then admitted to a
nursing home for short-term rehabilitation to
include physical therapy to improve muscle tone,
balance and strength. Stan arrived at the nursing
home with a history of congestive heart disease
requiring medication monitoring and observation by
a skilled nurse during the rehabilitation process.
Stan’s wife passed away two years ago; he has
managed to live independently and alone using a
Housing Choice Voucher to afford rent low income
housing tax credit development for seniors located
in a downtown urban area where he has been a
resident since turning 62, over 15 years ago. The
following are the service and housing action steps
that were implemented to safely transition Stan
back to the community.
“Do you want to talk to someone about the
possibility of returning to the community?”
MDS 3.0 Section Q
When Stan was admitted to a nursing home, his
daughter from out of state and his son who lives in
the area arrived to help Stan navigate his way
through what often can be a very confusing and
disorientating nursing home admission process,
especially for an older adult. During the admission
meeting, Stan seemed to understand the plan—he
was told that he needed approximately 30 days of
intensive physical therapy (PT) before returning
home. Stan emphatically “stated” yes to the
admission staff person’s question “do you want to
talk to someone about the possibility of returning to
the community?” Stan’s son, on the other hand,
voiced reservations, speaking up about Stan’s
struggles of living independently and alone after the
loss of his wife. Stan’s son disclosed that he
recently received a phone call from the property
manager at Stan’s apartment complex complaining
that Stan has repeatedly attempted to enter the home
Stan’s Path Out of an Institution
of several of his neighbors thinking he was opening
live alone in the community. Stan’s daughter
his apartment door and he is frequently spotted in
immediately started asking questions about
the neighborhood looking confused and disoriented,
community living –she wanted to know what kinds
requiring the assistance of a friendly passerby to
of supports and services were out there for her
guide him home. A nurse attending the admission
father, who paid for the services, how does one
meeting suggested that Stan may be experiencing
apply and become eligible for services, who could
the beginning stages of dementia or Alzheimer’s
help with ensuring that her father would be safe
disease.
living in his home? The nursing home staff admitted
Stan’s daughter recognized and accepted Stan’s
strong desire to return home as soon as possible.
Several hours later, Stan’s son and daughter felt
comfortable with Stan’s situation—his belongings
were unpacked for what was to be a short stay in the
nursing facility, he attended his first PT session, and
he enjoyed a meal in the dining room—so they
to having limited experience with helping an older
adult with complex health needs identify resources
and programs for community living. The frail older
adults that the nursing home has discharged had all
returned to the community to live with a family
member or to live in an adult assisted living facility.
prepared to leave Stan for the night. Stan
MFP Receives Section Q Data
immediately became confused and insisted that he
The Local Contact Agency in each state receives
was going back to his home in the city that evening
data indicating if a person in a nursing home is
and could not understand why he was being forced
interested in talking to someone about returning to
to stay in a nursing home.
the community. In Stan’s state the MFP program
The next few days were very rough for Stan; he
experienced multiple events of dizziness, fatigue
and often felt weak; his confusion and
disorientation rapidly escalated. Stan developed an
infection related to an incontinence issue and began
a regimen of antibiotics. Stan’s daughter insisted
that if Stan returned home he would no longer feel
so confused and he would not be as susceptible to
picking up infections. Stan’s son disagreed, thinking
that Stan might need to stay indefinitely in an
institution. Stan’s daughter reached out to the
uses this data to develop an Options Counseling
Program to reach persons in nursing homes who
have stated a preference for community living to
better inform them about the availability of
transition and Home and Community Based
Services (HCBS). To be more proactive, the state
recently developed a partnership arrangement
between the MFP Program and the local Aging and
Disability Resource Center (ADRC) to provide
options counseling about HCBS for persons in
institutions thinking about living in the community.
nursing home staff—however, the nurses and social
workers did not seem to have a lot of information or
knowledge about how a person such as Stan could
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Stan’s Path Out of an Institution
Fortunately, Stan’s PT is progressing and he has
AAA ADRC Lead Agency Sends Outreach
Coordinator/Options Counselor
regained strength in his hip and he is now able to
Stan’s daughter learns about the local ADRC by
use a walker to ambulate in the nursing home
searching the internet; she places a phone call to the
hallway. The nursing home staff informs Stan and
ADRC and is quickly offered assistance and
his family that he has met his rehabilitative goals
guidance on how to schedule an appointment for a
and will no longer receive benefits under Medicare
staff person to come to the nursing home to meet
Part A for his nursing home stay. Stan, however, is
with Stan and family members he wants present to
still feeling weak and his infection has not cleared
talk about community living services. At the
up. Stan’s son demands that Stan remain in the
meeting, an ADRC staff person informs Stan and
nursing home until he is 100% recovered. A 30 day
his son and daughter about the different types of
medical/health assessment is conducted and it is
supports and services and programs available to
determined that Stan still needs inpatient skilled
older adults who want to live in the community.
care. The social worker inquires about Stan’s assets
Even though Stan has resided in a nursing home for
and Stan is fairly certain that his bank account
less than thirty days, the ADRC staff person
always seems low, especially after paying his rent.
suggests that an education/outreach person from a
Stan’s son and daughter also confirm that Stan lives
local Center for Independent Living meet with Stan
on a limited Social Security income and has a few
and his family to further explain the technical
thousand dollars in savings. Stan is moved from the
details of how to qualify for HCBS and to begin the
short-term rehabilitative wing of the nursing home
application process for applying for State Medicaid
to a long-term care corridor. Medicare continues to
services. Stan and his family have trouble
pay for Stan’s nursing home stay, but now a co-
understanding the difference between Medicare and
payment of @ $130 a day is required. The nursing
Medicaid and are now concerned about incurring
home social worker suggests contacting the local
medical expenses for a longer stay in the nursing
Department of Social Services (DSS) to begin
home and are still confused about how Stan would
looking at applying for the Medical Assistance
pay for supports and services enabling him to live at
program.
home. In addition, Stan’s daughter is concerned
Stan’s daughter has now returned to her home 300
about all of the new medications that Stan has
miles away, but continues to seek information to
recently been prescribed by the nursing home
doctor—how much will Stan spend on out-ofpocket medical expenses when he returns home?
Stan continues to insist that he wants to go home,
but now he cannot remember his address or when
he last paid his rent and he thinks he may have left
his water running in the kitchen.
help Stan eventually return to his apartment. Stan’s
daughter calls the ADRC again with questions
about his Medicare coverage. The ADRC staff
person transfers the call to a case worker in the
State Health Insurance Assistance Program (SHIP)
and that person explains how an individual in a
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Stan’s Path Out of an Institution
nursing home who is low income can apply for
transition coordinator from the CIL agrees to meet
Medicaid benefits that may include payment for a
with Stan and his family regardless of whether or
Medicare premium, deductible, and coinsurance and
not he currently qualifies for MFP to explain the
copayment amounts. Stan’s daughter insists that
community services and supports options available
Stan will be returning home as soon as she is able to
for Stan.
figure out how to set up community supports and
services. The ADRC staff person suggests that Stan
and his family meet with a transition coordinator
Initial Assessments/Verifications for
Community Living
from the Money Follows the Person (MFP) program
A transition coordinator meets with Stan and his son
even though Stan does not technically qualify for
and Stan’s daughter joins the meeting via phone.
MFP yet.
The transition coordinator explains how a person
HCBS options explained
can apply for a waiver program that provides
supports and services in the community for an older
»
Informed Choice process
adult transitioning from an institution. Stan’s
»
Person decides to move to the community
daughter is relieved to learn that a personal care
»
Person chooses appropriate HCBS transition
attendant is a waiver service and that the services
and community living services and support
program (HCBS Waiver/MFP)
• Completion of Community Medicaid
Application (Medical Assistance/MA)
include help with meal preparation, light
housekeeping, bathing and dressing, personal
hygiene and other activities of daily living. Stan’s
son asks if this program includes assisted living,
stating that he thinks Stan will be safer living in an
MFP/State Medicaid Entity Contacts
Transition Coordination Entity
assisted living arrangement rather than in his own
The ADRC staff person calls the local Center for
Stan has never had Medical Assistance before and
Independent Living (CIL) who is contracted by the
also learns that Stan is continuing to pay his $600a
State Medicaid Office to provide transition
month rent for his apartment home. Stan tells the
coordination for the MFP program and explains
transition coordinator that he misses his friends at
Stan’s situation stating that Stan’s daughter is from
the apartment complex even though they have come
out of town and would like to obtain information
to visit him on several occasions at the nursing
about how to connect Stan to community supports
home. Stan’s daughter asks for more specific
and services even though Stan has not been in a
information about personal care attendants—she
nursing home long enough to qualify for MFP. Stan
wants to know who is responsible for hiring a
has been in a nursing home for 32 days, 22 days for
personal care attendant, who decides what the
rehabilitation after a 5-day hospital stay, and 10
attendant’s responsibilities are, what happens if a
days of daily skilled nursing assistance. The
care attendant does not show up and how does one
apartment. The transition coordinator confirms that
4
Stan’s Path Out of an Institution
go about firing a care attendant, are family members
agency if he is deemed eligible for the Medicaid
able to communicate with a care attendant on a
Waiver program.
regular basis, can a care attendant drive Stan to
doctor appointments or take him shopping? The
transition coordinator explains the difference
between a consumer-directed model and agency
model for providing the service of a personal care
• Verification and documentation of financial
status
• Verification of Level of Care to meet LTC for
NF criteria
attendant.
Stan and the nursing home social worker begin the
process of applying for Medical Assistance and the
first order of business is to collect all of Stan’s
financial information. Stan’s son attempts to assist
Stan with contacting his bank and Social Security,
but does not have the authorization to obtain Stan’s
documentation. Stan and Stan’s son decide that it
might be helpful if Stan designates his son as his
financial Power of Attorney; Stan’s transition
coordinator connects Stan and his son to a
community legal service to help Stan designate a
POA to handle his financial paperwork.
Initial Transition Planning
Stan’s daughter stays actively involved with helping
her father achieve his goal of returning to his
apartment in the community. Stan’s son continues
to seek additional information about assisted living
options; he learns that Stan would be responsible for
choosing the assisted living facility, Stan would be
required to forfeit most of his monthly Social
Security check to the assisted living facility, his
housemates would be pre-determined and other
choices would be limited such as food selections
and care providers. The assisted living facility
would, however, provide around the clock
The Medical Assistance Application is dropped off
supervision, meal preparation, and there would be
at the local Department of Social Services (DSS)
no stress associated with paying monthly rent or
office for review and processing, at least a 30 day
utility bills. Stan’s son also thought about the more
process.
recent problems Stan was encountering from
Stan is met by a case manager from the local Area
on Aging (AAA) the following week to conduct a
universal assessment to determine Stan’s medical
eligibility for long-term care and to assist with
development of a plan of care and service plan. The
case manager informs Stan that he will have access
to a case manager once he transitions to the
community to help him coordinate his community
living supports and services from the same AAA
unknowingly disturbing his neighbors to getting lost
within blocks of his home. Stan was dismayed
whenever assisted living was mentioned as an
alternative to returning to his home on the sixth
floor of the senior apartment development located
on a busy but neighbor friendly street providing
Stan access to amenities he has used and needed for
the last 15 years—grocery store, bus stop, cleaners,
pharmacy, and a library and senior center.
5
Stan’s Path Out of an Institution
Stan is approached by the nursing home social
incontinent supplies. Stan’ AAA case manager
worker who tells him that he now qualifies for
explains that those types of medical supplies are
Medical Assistance and as of this day Medicare will
generally covered by Medicaid, but typically not
no longer pay daily nursing home fees. The social
covered by Medicare and Stan will be returning to
worker hands Stan his new Medicaid identification
the community under a Medicaid waiver program.
card and informs Stan that his Patient-Pay amount is
Stan’s daughter spoke up about Stan’s desire to
$1500.00 a month. Stan has resided in a nursing
return to a home and community that provides
home for 53 days under Medicare; if Stan meets the
familiarity, security and comfort for him. The
technical, medical and financial criteria for the older
transition coordinator informs everyone that Stan
adults Medicaid Waiver program he can begin to
can continue to pay his rent by requesting that the
receive services in the community after another 30
nursing home business office contact the local
days of residence in a nursing home.
Department of Social Services (DSS) office to
A case manager from the AAA schedules a meeting
with Stan and his family members and the transition
coordinator to review Stan’s medical assessment
and to begin the process of looking at what kinds of
supports and services Stan is eligible to choose from
so that he can live independently in the community.
request a diversion of income from Stan’s monthly
Social Security check so that Stan can continue to
pay his $600 a month rent. Stan confirms that he
intends to return home and that his rent needs to be
paid.
• Transition Coordinator and person desiring to
Stan’s daughter drives 300 miles to attend the
transition and family/friend supports if
meeting and Stan’s son who lives nearby also
requested by the individual meet to review
attends. Stan has recovered from his hip fracture but
assessment and determine community living
will now need to use a walker for balance and fall
service and support needs. Person identifies
prevention. Stan’s fatigue has been associated with
assets, strengths, and preferences.
congestive heart disease, requiring multiple daily
medications.
Housing Referral
Stan’s AAA case manager facilitates the meeting,
The transition coordinator obtains a signed consent
listening to Stan’s son express concern about the
to release information form pertaining to housing so
safety and health issues surrounding Stan’s
that the property manager of Stan’s apartment
challenges of coping with his confusion and
complex can be contacted to coordinate Stan’s
disorientation while living alone in the community.
eventual return home. When the transition
In addition, Stan’s son reveals that he has become
coordinator contacts the property manager, a
even more concerned because as he was reviewing
problem arises with confusion over Stan’s unpaid
Stan’s financial paperwork, he noticed that Stan was
utility bill. The electricity has been shut off and
spending what appeared to be over $300 a month on
maintenance staff recently had to enter Stan’s
6
Stan’s Path Out of an Institution
apartment to get rid of the odor from rotted and
suggests seeking services from an occupational
spoiled food in the now turned-off refrigerator. In
therapist during the first few weeks of Stan’s
addition, the property manager began to ask the
transition back home. Stan’s son remains skeptical
transition coordinator about Stan’s ability to live
about Stan’s ability to live independently and
independently if he returned to his apartment. The
continues to explore the option of assisted living.
transition coordinator decides to meet with the
Stan’s daughter reminds everyone about Stan’s
property manager in person to discuss these
wide network of friends in his apartment building
immediate issues and to share information about
and his long-term familiarity with his
Fair Housing practices. The property manager
neighborhood. The transition coordinator offers
informs the transition coordinator that Stan may not
information about a new program that has just been
continue to hold onto his apartment after 180 days
initiated that provides peer support for persons
of non-occupancy and informs Stan’s transition
interested in leaving a nursing home to live
coordinator that Stan’s temporary absence should be
independently in the community. Stan’s daughter
reported to the Public Housing Authority (PHA).
thinks this would be a great opportunity and
The transition coordinator estimates that Stan will
encourages both Stan and his son to take advantage
be able to return home within 30-45 days.
of meeting a person who has experienced some of
the same challenges as Stan.
Transition coordinator obtains basic information
about a person’s aspirations to live in a home of
their own in the community. This information is
submitted to a housing coordinator who will
conduct a comprehensive housing assessment and
directly assist a client with locating and securing
an affordable housing opportunity.
The AAA case manager states that the universal
assessment conducted the previous week indicates
that Stan has intermediate care needs and that he
may also be eligible for a new service available
under the older adults waiver—Telecare. The case
manager explains that this service uses in-home
technology to assist and support a person to
maintain his independence by monitoring health
Plan of Service
status, medication dispensing, and passive safety
The case manager from the AAA continues to
monitoring.
gather information from Stan and his family
members about the types of services and supports
Stan is hoping to access when he returns home.
Particular emphasis is placed on Stan’s safety,
especially when Stan becomes disorientated. Stan
expresses some fear and concern about falling again
in his apartment. The transition coordinator
Stan’s AAA case manager explains the cost of
disposable medical supplies (DMS), specifically
incontinent supplies and the limitations on the brand
and type of supplies that can be offered to Stan.
Stan has now been in a nursing home for 3 months
and his mental faculties seem to continue to decline
as he does less and less for himself including
7
Stan’s Path Out of an Institution
performing basic mental processes of thinking about
a narrative in the POS outlining the backup plan.
what he is going to eat for dinner to making
Stan’s POS is sent to the State Office of Long Term
decisions about how he is going to spend his free
Living under the State Department of Aging and
time. The decline has also impacted Stan’s ability to
Public Welfare for review and approval.
self-monitor his daily medicine regimen. Stan’s son
sees this general decline as a warning sign and
decides that Stan should visit one or two assisted
living facilities. Stan’s transition coordinator makes
a referral to the peer support program and provides
a list of assisted living facilities to Stan and his son.
Stan still has not met the qualifying time period to
become eligible to receive MFP benefits; he has
Stan is visited by a peer mentor, a person with a
disability who transitioned from a nursing home
eight years ago and is currently living in a senior
public housing development in the city. Stan learns
about how this person’s home has been modified to
make it safer and more accessible.
• Transition Coordinator incorporates input from
now been in a nursing home for 90 days, only 37 of
person desiring to transition, medical/health
which count toward the 90 required under MFP.
assessment, and other information obtained
Stan’s transition coordinator proceeds with planning
for Stan’s return to the community, knowing that
Stan must return to his apartment home before a
total of 180 days of non-occupancy elapses.
The AAA case manager takes all of the information
and thoughts from Stan, Stan’s son and daughter,
and from the medical/health assessment and the
nursing home staff and, with Stan at the center,
begins to write a Plan of Service (POS). The AAA
from professional medical/health/social staff to
develop plan of service that will provide
adequate supports for person to be safe and
healthy in the community and to assist person
desiring to transition to achieve community
living goals.
• Plan of Service is sent to State Medicaid HCBS
approval entity for verification of eligibility.
Plan must contain a 24-hour emergency backup
plan.
case manager incorporates Stan’s goals and the
recommendations from the medical/health
assessment and specifies the exact services, durable
medical equipment, disposable medical supplies,
adaptive technology, environmental modifications,
home health services, physical and occupational
therapies and other supports deemed necessary for a
safe and healthy transition to the community. The
services and supports are assigned exact dollar
figures. Stan has identified his son as an emergency
backup person and the AAA case manager includes
Eligibility
Stan’s POS is reviewed by a team of administrators
in the State Office of Long Term Living, generally a
two week review process unless a service or cost
requires additional review. In Stan’s state, the plan
must meet the technical criteria of cost-neutrality in
order for Stan to be approved to participate in the
HCBS Waiver program and the requested services
and supports must meet the State’s criteria for being
8
Stan’s Path Out of an Institution
necessary and sufficient to promote a safe discharge
county agency responsible for verifying if a person
and a healthy community living environment. The
in a nursing home has the need for long-term care
State Long Term Living office questions Stan’s
services has also sent notification to the State Office
request for Financial Management Services to help
on Long Term Living – Stan has a nursing home
with payroll and tax paperwork for the consumer
level of care (LOC) and he meets the medical
directed personal assistance model because the POS
criteria for the HCBS Waiver. The State Office on
indicates that Stan has chosen the Agency Model.
Long Term Living finally issues a notification to
The AAA case manager re-reviews the plan and
Stan letting him know that he is eligible to receive
notices that an error exists; Stan will be utilizing the
services through the HCBS Waiver program. Stan
Agency Directed Model and will not need Financial
has now been in a nursing home for 163 days—110
Management Services. The corrected POS is sent
days of which count under MFP as they are not
back to the State Office of Long Term Living. The
Medicare short-term rehab days. Stan’s transition
public agency committed by the State to determine
coordinator is closely monitoring Stan’s time in the
the financial eligibility for HCBS programs sends a
nursing home knowing that he must discharge
denial notice to the State Office of Long Term
before 180 days are up in order to hold onto his
Living indicating that Stan’s assets exceed $2000
community apartment. The AAA case manager has
and therefore he does not meet financial eligibility.
been busy coordinating, tracking and monitoring the
Stan’s son and daughter investigate Stan’s assets
verification process for three separate eligibility
and it is discovered that Stan holds a life insurance
qualifications and three separate entities processing
policy with a cash value of $5000.00 and somehow
the verifications to determine whether Stan is
this was missed or overlooked when Stan applied
eligible to Home and Community Based Services—
for Medicaid last month. Stan’s daughter calls the
a state agency, a private contractor, and a county
local ADRC and is referred to the SHIP Office
government agency.
where she receives guidance on how to report the
•
Financial
liquidate the policy and spend down on care.
•
Medical
Several week s of phone calls to various agencies
•
Technical
life insurance asset to Medicaid and how to
and entities to resolve the asset issue ensued and
finally it was determined that Stan’s state of
residence allowed for a final expense policy to be
Identify Community Transportation
Options
kept or transferred to a funeral home (but the
Stan has a discussion with his transition coordinator
funeral home would keep the entire death benefit)
about community transportation and he states that
and therefore the cash value would no longer be
he has been using the public bus system for years; a
counted as an asset. This asset verification and
bus stop is located on the same block as his
transfer took almost 2 months to complete. The
apartment complex and in addition his apartment
9
Stan’s Path Out of an Institution
building provides a weekly shuttle bus to a
cannot be asked about a tenant’s health, medical, or
shopping mall. The transition coordinator informs
disability status.
Stan that he will now be eligible for Medicaidstops in front of Stan’s apartment building. Stan
reports that he generally takes the bus to his
doctor’s office funded transportation for non-
• Transition Coordinator submits referral to
Housing Coordinator
• Housing Coordinator focuses on assisting a
emergency medical visits that includes bus passes
person locate and secure affordable housing;
on the fixed route that stops in front of Stan’s
transition coordinator focuses on health and
apartment building. Stan reports that he generally
safety
takes the bus to his doctor’s office.
Housing Assessment
Approved for HCBS Eligibility
Because Stan is returning to his previous residence,
Stan receives approval notification for the HCBS
the transition coordinator conducts a more limited
Waiver program—he meets the financial medical
housing assessment that confirms Stan’s high
and technical criteria. Stan has been in a nursing
satisfaction with his current apartment and
home for a total of 167 days to date.
community and his long-term stable rental history.
• Housing Coordinator conducts an initial housing
Locating and Securing Community
Housing
assessment to determine person’s strengths and
Stan’s transition coordinator has been in close
reviews clients personal housing history
contact with the property manager of Stan’s
including successes and challenges, identifies
apartment building over the last 2 months to
possible barriers to housing, and maps out
coordinate the utility payments and to ensure that
strategy(s) to achieve community living goal(s)
assets and community housing preferences,
the nursing home continues to withhold Stan’s rent
from his Social Security check. In addition, Stan’s
Housing Documentation
transition coordinator met with the property
Stan is notified while he is in the nursing home that
manager to provide insight and guidance on Fair
an annual recertification for the Low Income
Housing Laws that protect the privacy and rights of
Housing Tax Credit program must be completed
persons with a disability—this meeting was
within the next 60 days to include verifying his
precipitated after the property manager asked
current income. In addition, a file review was
several questions about Stan’s ability to live
conducted by the property manager and it was
independently. The property manager now better
noticed that Stan’s birth certificate was missing and
understands boundaries regarding what can and
his wife’s death certificate was never submitted to
the property manager. Stan’s transition coordinator
10
Stan’s Path Out of an Institution
assists Stan with obtaining the documents; a copy of
Stan’s transition coordinator is now in daily contact
Stan’s birth certificate is provided by Stan’s
with the AAA case manager and Stan’s family
daughter and an on-line application is submitted to
members to assist with keeping the discharge
the Department of Vital Records requesting the
planning on track. Apparently, Stan’s son is still
death certificate. The LIHTC annual recertification
pushing Stan to move into an assisted living facility.
also coincides with an annual recertification for the
Housing Choice Voucher program.
• Housing Coordinator begins process of
acquiring all required housing documentation to
include Social Security card, birth certificate,
government-issued id, updated income and asset
documentation
Housing Barriers
• Housing Coordinator assists with reviewing
credit, criminal, and housing history
• Determine action step(s) to overcome
challenges
Housing Applications/Programs
• Affordable housing opportunities identified as
appropriate to individual preference(s)
• Submit applications to affordable housing
• Track status of application(s) and monitor wait
list status
• Track status of program application(s)
Housing Program Orientation/Eligibility
Process
• Assist client with HCVP orientation
• Assist client with eligibility process for PH and
HUD Multi-Family developments
Housing Search (HCVP)
• Conduct housing search if person has HCV
Independent Life Skill Goal Achievement
As the reality of transitioning back to his apartment
becomes more apparent, Stan begins to work
closely with his AAA case manager and staff at the
nursing home. Stan’s AAA case manager has been
programs such as Housing Choice Voucher
in touch with Stan’s son frequently over the past
Program (HCVP)
several weeks to discuss assisted living options and
• Submit applications for Public Housing (PH)
waitlist and HUD Multi-Family waitlist
Stan’s son continues to voice concern about Stan’s
ability to live safely by himself. The AAA case
manager continues to involve Stan in these
Housing Tracking and Monitoring
discussions and Stan confirms his intent to return to
Stan’s transition coordinator continues to track and
his apartment. Stan’s AAA case manager addresses
monitor Stan’s readiness to return to his community
apartment home in order to ensure that Stan returns
home within 180 days of vacating his apartment.
the concerns by continuing to explain the supports
and services Stan will be receiving once he returns
home—Stan will have access to the new in-home
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Stan’s Path Out of an Institution
technology Telecare that will provide 24/7
• ADL Needs
monitoring, 6 hours a day of personal care service
• Training for medical dispensation and
providing Stan assistance with housekeeping, meal
preparation, dressing and bathing and other routine
daily health and living needs, home health services
including occupational therapy services to help Stan
create a safe home environment and to establish fall
monitoring if needed
• Training/guidance/coaching for how to
interview, hire, and fire personal care attendants
prevention protocols, and a daily home delivered
Community Resource Connection
meal. Stan’s AAA case manager will also be
Stan was well-connected to the community before
helping Stan to identify a neurologist to work with
entering a nursing home. Stan was an active
Stan on his disorientation and memory symptoms.
participant in several of his senior apartment
Stan’s daughter has been in frequent contact with
building sponsored functions and outings. In
the AAA case manager and she feels confident that
addition, Stan seemed engaged with his broader
Stan can adjust to safely living at home and she
community when he was living on his own and
reminds Stan’s son (her brother) that he has been
many of his friends from his apartment complex
granted POA rights and he will be able to closely
took the time to visit him in the nursing home. Stan
monitor Stan’s bill paying and other financial
has been visited by the same peer support person
affairs. Stan’s transition coordinator urges Stan and
once a week for the last two months; Stan has used
his family to plan a discharge date that provides
this face-to-face time to ask a lot of questions about
enough leeway to ensure that Stan does not exceed
how his life might be different than what is was like
the 180 day non-occupancy rule of his apartment
before his fall. Stan is mostly concerned about
complex. Stan has been out of his unit for @ 169
being a burden on his children and losing some of
days to date.
his independence and he is not sure if he is going to
Stan meets with his peer support mentor and
together the two of them plan a community outing
to include a visit to the peer mentor’s neighborhood
and apartment complex. Stan’s son is invited to
come along and after the outing Stan’s son states
that he is beginning to believe that with the right
kinds of supports and services, Stan could live
safely in his apartment.
• PT Needs
• Transfer Needs
enjoy having a personal care attendant come to his
home every day. Stan admits that he sometimes gets
a little scared when he thinks about the possibility
of falling again and he does not want anyone
helping him to bathe. Additionally, Stan revealed to
the peer support person that over the last year or so
his life was getting a little more limited—for
example, he no longer felt safe on his own after
dusk and he decided over a year ago not to travel
beyond the local grocery story which was only two
blocks away, if he was out by himself. He stated
that he felt humiliated a number of times when he
12
Stan’s Path Out of an Institution
could not navigate his way home from the library or
• Referrals for household budgeting counseling
other places that were no more than ten blocks away
• Referrals for entitlements affecting housing
from his apartment complex.
• Substance Abuse/Mental Health
Coaching/Counseling
affordability (food stamps, utility/energy
assistance, etc.)
• Referrals for behavioral health specialists
• Peer Mentoring
Pre-Discharge Planning
Secure Housing
• Lease signing, security deposit
• Good tenant training
• Identify possible reasonable modification(s)
needs
• Coordinate environmental modification funding
and contractors
Incorporating Service Plan Options to
Address Housing Problem Areas
Stan’s transition coordinator explains how an
automatic rent payment plan can be set up and Stan
agrees that this type of payment system would be a
good option for him. Stan’s transition coordinator
obtains forms and paperwork from both Stan’s bank
and property manager and meets with Stan’s son to
complete the process steps for establishing an
• Pre-discharge planning meeting(s) to include all
appropriate medical/health professionals and
person desiring to transition identified personal,
family, and community supports.
• Identification of transition tasks
Discharge Planning
Stan’s transition coordinator continues to stress the
urgency of moving forward with Stan’s discharge
so that Stan does not exceed the 180 day nonoccupancy limit for his apartment. Stan’s son has
reluctantly agreed to support Stan’s move home. A
discharge planning meeting is scheduled—the
meeting is attended by Stan, Stan’s daughter, Stan’s
son, the new personal care attendant, Stan’s
transition coordinator and AAA case manager, the
nursing home social worker and nurse.
coordinator also provides information to Stan and
Identify Community Primary Care Physician
(PCP)
his son about setting up a utility payment system
Stan has a community PCP that he has been seeing
referred to as “budget billing” providing a
for the past ten years and whose office happens to
consistent monthly utility bill based on year long
be in Stan’s neighborhood. Stan’s AAA case
averages rather than having to budget around
manager is having difficulty identifying a
monthly and seasonal fluctuations.
neurologist within Stan’s community or on the local
automatic rent payment plan. Stan’s transition
• Rent payment plan
bus line that accepts Medicare-Medicaid dual
eligible coverage.
13
Stan’s Path Out of an Institution
• Identify Community Pharmacy
manager provides information about making
Stan has been prescribed multiple new
homes safer by reducing tripping hazards and
medications to deal with his congestive heart
improving lighting. Stan’s son confirmed that
failure condition. The AAA case manager
Stan’s apartment has grab bars in the bathroom,
informs Stan that he may be eligible to
in the shower and next to the toilet.
participate in a Medication Therapy
»
Coordinate PT/OT
Management (MTM) that will include a free
»
Identify modification provider
discussion by a pharmacist or other health
»
Obtain State Medicaid approvals for
professional to help Stan use the medications
environmental modifications
safely. Stan’s daughter asks about the added
»
Set up community medical appointments
expense of these new medications –will Stan
»
PCP, Dialysis, Drug Treatment, Mental
have a higher Medicare D premium and higher
Health Provider, SA/NA Meetings, Wound Care
deductible and additional co-pays? Stan
Clinic, Methadone Center, Lab Center
mentions that his pharmacy is located in the
grocery store within walking distance of his
home. Stan’s AAA case manager coordinates a
meeting with the SHIP office to review Stan’s
Medicaid prescription plan and to ensure that
Stan’s new medications are on Stan’s current
plan.
• Coordinate Environmental Modifications
• Coordinate Personal Care Attendant Needs
Stan’s daughter has been helping Stan to select a
care attendant from a care attendant agency
recommended to Stan by his peer support
mentor. Stan’s daughter has been contacting
attendants on Stan’s behalf from her home 300
miles away and managed to set up 3 interviews
this week. One person being interviewed
Stan’s AAA case manager informs Stan and his
previously provided personal care for an older
family that an Occupational Therapist (OT) is
adult who used to live in Stan’s same apartment
currently not available; a search is underway to
building. Stan’s transition coordinator reminds
identify and enroll a pool of OT specialists into
Stan’s daughter that a care attendant must be
the State Medicaid program. Stan’s son and
chosen quickly or else Stan faces the possibility
daughter voice concern about the possibility of
of losing his apartment if he does not discharge
Stan falling again in his apartment, especially
within the next ten days.
without professional advice from an OT. Stan’s
nurse who has been working closely with Stan
during his nursing home stay stated that a
Educate/explain consumer care models
(agency/consumer)
review of all his medications is underway to
»
Coordinate provider resources/contact
look for any side effects or drug combinations
information
causing dizziness or drowsiness that could
»
potentially cause Stan to fall. The AAA case
responsibilities
Coordinate personal care attendant tasks and
14
Stan’s Path Out of an Institution
• Coordinate Emergency Back-up Plan/Informal
• Coordinate Community Resource Referrals
Supports
»
Food stamps
Stan’s son has volunteered to be available in
»
Energy Assistance
case of emergency but has unreliable
»
Vocational
transportation. Stan’s son does not own a car,
»
Educational
but he frequently borrows his neighbor’s car to
run errands.
• Order Durable Medical Equipment/Durable
Medical Supplies
• Coordinate Access of Transition Funds for
Stan’s transition coordinator continues to follow
up with the local utility company regarding
Stan’s budget billing application. Stan does not
want to apply for food stamps—he feels that he
managed his food budget adequately before
Necessary Home Living Needs
entering a nursing home and the home meal
»
Basic Furniture
service will allow him to reduce his weekly
»
Basic household necessities
»
Security Deposit
• Coordinate Access to MFP Flex Funds for
Necessary Community Living Needs
Stan’s transition coordinator suggests that
Stan’s apartment undergo a full cleaning before
he returns home. Stan’s son agrees and states
that the kitchen is a mess and the refrigerator
has not been cleaned in what appears to be for
the last several years. Stan’s son states that he
cannot help with any of the cleaning tasks
because of his current health situation. Stan’s
transition coordinator offers to coordinate a
referral to a cleaning service and will check with
the state MFP office to request if MFP flex
funds can be accessed to pay for a one-time
cleaning service prior to Stan’s move home.
• Coordinate Community Registrations
»
Fire, police
»
Utility/phone hook-ups
grocery bill.
• Coordinate Completion of Quality of Life
Survey
Stan’s transition coordinator meets Stan in the
nursing home to complete the Quality of Life
Survey. Stan’s answers to the survey indicate
that he is looking forward to having choice and
control back in this life.
• Coordinate Discharge Day Medical Prescription
Requirements
Stan’s AAA case manager receives notification
that Stan’s medications have been changed
because it was determined that several
medication combinations were causing Stan to
feel both dizzy and drowsy. The AAA case
manager calls the SHIP office in an effort to
determine if the new drugs are covered under
Stan’s Medicaid Part D Prescription Plan
Formula. The AAA case manager suggests that
Stan delay his discharge until confirmation of
his prescription drug coverage is received.
Stan’s transition coordinator reminds everyone
that Stan must discharge within the next 48
• Coordinate Home Meal Preparation
15
Stan’s Path Out of an Institution
hours or else he will lose his apartment. Stan’s
apartment has been unoccupied for 178 days.
Stan will be returning to his apartment home
The SHIP office calls back with the news that
Stan’s AAA case manager and transition
three of the drugs are not covered under Stan’s
coordinator are at the apartment complex when
Plan Formula. Stan cannot afford to pay for
Stan returns home to assist with moving day
these drugs out of pocket. Stan’s AAA case
logistics. A two week supply of groceries is to
manager suggests filing for an exception to have
be delivered today along with a delivery of
the drugs be provided by the plan. Stan’s AAA
disposable medical supplies.
case manager consults with the SHIP office and
Stan’s AAA case manager arrives at Stan’s
then files an expedited coverage determination.
apartment on move-in day to meet with a
The next day, Stan’s AAA case manager spends
technician who is installing telehealth sensory
several hours on the phone trying to confirm the
monitors which includes a bed sensor,
status of his prescription coverage. As a backup,
refrigerator/stove sensor and a general motion
the AAA case manager consults with medical
detector. Telehealth is a new pilot Medicaid
staff at Stan’s nursing home to determine if a 30
Waiver program coordinated by the AAAs in
day supply of the uncovered drugs can be
Stan’s state. Stan included this service in his
provided to Stan so that he can discharge within
POS to help to sustain and promote his
24 hours to meet the apartment complex
independence at home and to facilitate early
deadline. The thirty days will give Stan’s AAA
intervention regarding any health problems.
after 178 days in a hospital and nursing home.
case manager enough time to figure out how to
obtain Medicare coverage for all of his
prescriptions.
• Coordinate Final HCBS Eligibility
Verification(s)
• Coordinate State Medicaid Notification of
How to be a Good Tenant
• Facilitate Relationships with property
manager, maintenance staff, new neighbors
• Review lease and tenant obligations
• Review rent payment plan
Discharge
• Coordinate Transfer of Entitlement Benefits to
Community Living Status
»
SSI/SSDI
• Coordinate Moving Day Logistics
Stan’s transition coordinator lets the property
manager know that Stan will be returning to his
apartment home within the 180 day time-frame;
30 Day Post Transition
• Conduct home visit
• Resolve any immediate community
health/safety issues
Stan’s AAA case manager makes several calls
regarding the three drugs that are currently not
covered under Stan’s Medicare Prescription
Plan and finally learns that these drugs will be
16
Stan’s Path Out of an Institution
included in the plan. Stan does, however, have
an immediate issue. Stan lets the AAA case
manager know that he cannot use the
incontinent supplies—they do not fit well and
are uncomfortable. Stan’s AAA case manager
makes multiple calls to other providers to
identify a better product but to no avail. Stan
refuses to use the current supplies resulting in a
daily need to wash sheets and other clothing, a
task not originally assigned to Stan’s care
attendant.
» OT assessment
• Verify delivery of furniture and other household
items
• Verify delivery and access to DME/DMS
services
• Verify delivery and access to Assistive
Technology
• Coordinate transfer to community Social
Security benefits (SSI/SSDI)
• Continue to coordinate community PCP
appointment/provide any necessary follow up
• Continue to coordinate community pharmacy
access/provide any necessary follow up
• Continue to coordinate attendant care
several interviews for a new attendant from the
same agency.
• Coordinate community mental health and/or
substance abuse services
• Coordinate PT and/or other community health
services
Stan’s AAA case manager continues to monitor
the availability of an Occupational Therapist
under Stan’s Medicaid Waiver program. Stan’s
AAA case manager discovers that a county
program exists that provides a home visit from
an aging in place specialist who has knowledge
and resources regarding how to make a home
safer for older adults. Stan agrees to request a
referral to this program. Stan’s AAA case
manager finally identifies a neurologist; the
office is located outside of the city, in a
neighboring suburban county. Stan’s AAA case
manager begins to work on coordinating a
transportation plan to get Stan to his neurologist
appointments that involves arrangements with
multiple jurisdictions and corresponding
transportation systems.
• Continue to coordinate environmental
modification needs
services/provide any necessary follow up
Stan’s AAA case manager continues to monitor
Stan’s AAA case manager receives several
the availability of an Occupational Therapist
complaints from Stan about his personal care
under Stan’s Medicaid Waiver program. Stan’s
attendant. Stan’s AAA case manager facilitates
AAA case manager discovers that a county
a meeting and it is discovered that the personal
program exists that provides a home visit from
care attendant is not happy about having to wash
an aging in place specialist who has knowledge
soiled laundry. During the meeting, Stan decides
and resources regarding how to make a home
that he wants someone else for his personal care
safer for older adults. Stan agrees to request a
attendant. Stan’s AAA case manager arranges
referral to this program. Stan’s AAA case
17
Stan’s Path Out of an Institution
manager finally identifies a neurologist; the
»
RN visit
office is located outside of the city, in a
»
Status of identified community living goals
neighboring suburban county. Stan’s AAA case
manager begins to work on coordinating a
transportation plan to get Stan to his neurologist
appointments that involves arrangements with
multiple jurisdictions and corresponding
transportation systems.
• Continue to coordinate environmental
modification needs
Post Transition (Month 2 - 12)
• Conduct monthly phone contact to obtain health
• Submit Reportable Event(s) if necessary and
continue to provide follow up
• Assist with linkages to community resources
• Monitor health and safety
»
Care Attendant services
»
Nursing supervision
»
Therapy
»
AT/DME needs
»
Environmental modification needs
• Continue to review POS
update, psychosocial, and housing update or
»
Is POS still meeting client’s needs?
other updates as requested by a participant
»
Is client receiving all services listed on
POS?
Housing Stabilization (On Going)
»
• Provide strategies and interventions for
POS to better meet health and safety needs?
preventing tenant problems
• Connect to community resources
• Manage tenant crisis
• Review affordable housing program obligations
such as annual recertification and annual
inspection
Does client require any modifications to
• Continue to review status of community living
goals
»
What are the goals from the previous
monthly contact?
»
What is the progress towards meeting these
goals?
»
What new goals have been identified?
• Exiting a housing program if necessary
Stan reunites with his friends and neighbors in
• Conduct quarterly home visit
his senior apartment complex and continues to
»
Health update
attend functions and activities sponsored by the
»
Psychosocial update
apartment complex. Stan begins to run errands
»
Safety issues
and travel around his immediate neighborhood
»
DME/DMS issues
with the assistance of his personal care
»
Care attendant provider updates
attendant.
»
POS review
18
Stan’s Path Out of an Institution
Month 12 of Transition
“Is your current POS still meeting your needs?”
“Are you receiving all services as listed on your
POS?”
“What is the progress toward meeting your
community living goals?”
“Do you still feel these goals are realistic?”
“What new goals have you thought about for the
next year?”
•
Annual POS Recertification
•
Annual Environmental Assessment
•
Annual housing recertification
19