Transcript Linking PASRR to Transition | Jennifer Glick and Megan Goodfield

National Mental Health & Aging
and PASRR Conference: March 24-25, 2014
Indianapolis, IN
Transitions result from…..
 Multi-pronged approaches to
rebalancing
 Ongoing Collaboration
Multi Pronged Approach to Rebalancing
Goal to transition individuals to least restrictive environment
 Mental Health Waiver/MFP
 Nursing Diversion and Transition Program
 Outreach and Engagement Project
Mental Health Waiver/ W.I.S.E. Program
 1 of 2 MH waivers in U.S.
 Operational since April 2009
 Assists clients to be diverted or discharged from NHs
 Linked to MFP
 Person-Centered, Recovery and Psych Rehab Model
 Recovery Assistant: hybrid companion, homemaker,
PCA, and respite
 Cost Neutrality
 www.ct.gov/dmhas/cwp/view.asp?a=290&q=425724
Nursing Home Diversion & Transition Program
 Nurse Clinicians and Case Managers assigned to



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geographic locations in state
Clarify/validate Level of Care (LOC) needs and services
Cross-trained with Mental Health Waiver program
Monthly meetings with NH staff and Money Follows the
Person (MFP) staff
Piloting groups in NH settings:
 Chronic disease self management
 Double Trouble for co-occurring Mental Illness & Substance
Abuse
 Community skills-building
Outreach and Engagement Project
 Outreach to residents in nursing facilities
 Education to nursing facilities, home care agencies,
behavioral health providers, community resources
 Ongoing engagement of residents
Shifting Culture
Institution vs. Home Based Care
Providers and Residents experience change
Collaboration through…..
 Keeping the conversation going & shared
responsibility.
 Public/Private input to Core Standardized Assessment
Tool.
 Consultation between waiver programs.
 Cross-agency/provider trainings and retreats.
 PASRR process & follow-up on Level II
recommendations.
 MDS Section Q prompts NH to refer to MFP
State of CT Overview
Medicaid Authority
PASRR and
Electronic Vendor
MH Authority
Statewide Services Unit
& PASRR
NHDTP
Key Offices
•MFP
•Alternate Care Unit
•Other waiver units
•EPS
MH Waiver
(W.I.S.E.)
Outreach and
Engagement
Community Placements
Others
•State DD Authority
•ADRCs
•State Dept. Public Health
•State Dept. on Aging
•Triple A’s
•LTC Ombudsman’s Office
•Nursing Homes
•Hospitals
•Independent Living Centers
•Community providers
Give a Hoot
Don’t Institute!!
Jennifer Glick, RN, MSW, 860-262-5818 [email protected]
Megan Goodfield, LCSW, 860-262-6953 [email protected]
CT Department of Mental Health & Addiction Services
www.ct.gov/dmhas