Transcript Powerpoint-Moving Home Minnesota

Moving Home Minnesota
A New Transition Solution
A Federal Money Follows the Person
Rebalancing Demonstration
June 2013
Agenda
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Overview and background
Violet’s Story
Ellen’s Story
Summary
Question and Answer
Learning Objectives
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After this training you will be able to describe
and identify:
– The goals of Moving Home Minnesota
– The eligibility criteria of Moving Home
Minnesota
– The role of a transition coordinator
– The enrollment process.
What is Money Follows the
Person?
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Federal Medicaid demonstration project
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Assists individuals with transitions from nursing homes or
institutions to community living
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Authorized by Congress through passage of the 2005
Deficit Reduction Act
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Allows states to develop, implement and evaluate
demonstration and supplemental services not otherwise
covered by the state’s HCBS waivers
What is Moving Home
Minnesota?
Moving Home Minnesota is the
name for Minnesota’s Money
Follows the Person Demonstration
project
Goals of Moving Home Minnesota
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Increase the use of home- and communitybased long term care services,
Eliminate barriers that prevent or restrict flexible
use of Medicaid funds for necessary long term
care services in the settings reflecting individual
choice, and
Increase the ability to assure continued
community-based long term care services to
eligible individuals after transition.
Mission Statement
Creating choice and opportunity for Minnesotans to
move from institutions to homes and communities,
live more independently,
and enhance the quality of their own lives.
Why Moving Home Minnesota?
Honor
choice
Medicaid
reform
Olmstead
planning
Community
Living
Federal
demonstration
project
Cost
effective
Increased
quality of life
for
participants
Systemswide
momentum
Moving Home Minnesota and
Related Initiatives
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Other programs
– Relocation Service Coordination
– Return to Community
– Housing Access Services
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How Moving Home Minnesota is different:
– Coordinated effort
– Access to enhanced services
– Potential for follow-up
Moving Home Minnesota
Vernacular
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Transition Coordinator
Demonstration Services
Supplemental Services
Person Centered Plan
Meet Violet
Individual Eligibility Requirements
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All age groups
One or more qualified institutions
– 90 consecutive days
– Excludes Medicare rehabilitative days
Medical Assistance has paid for at least 1 day of
institutional care prior to discharge.
Resident of Minnesota
Moving Home Minnesota
Qualified Institutions
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Hospitals
Nursing facilities
Intermediate Care Facilities for People with
Developmental Disabilities (ICF/DD)
Institutions for people with mental diseases
(participants under 21 or 65 years of age or
older).
Qualified Community Residence
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Single-family home owned or leased by the
individual or the individual’s family member;
Apartment with an individual lease, with lockable
access and egress, and which includes living,
sleeping, bathing and cooking areas over which the
individual or the individual’s family has domain and
control; or
Residence in a community-based residential setting,
in which no more than 4 unrelated individuals reside.
How to Access Moving Home
Minnesota
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Phone
– Senior LinkAge
Line®
– Disability Linkage
Line®
– Managed Care
Coordinator
– Case Manager
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Fax
– 651-431-7745
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Mail
– PO Box 64250
St. Paul, MN 551640250
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Online (available in
the future)
Enrollment Process
• Participant
identified
• Complete form
INTAKE
VERIFICATION
• DHS reviews
eligibility
• Notifies lead
agency
• Meet with
transition
coordinator
• Informed consent
ENROLLMENT
Recruitment Strategies
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Letters to potential participants
– Identified through MDS/MMIS data using MFP
criteria
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Referrals from facilities (including Section Q)
Referrals from providers and lead
agencies
– Long-term care consultation
What is the role of a Transition
Coordinator?
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Someone with experience relocating
people who use services.
Identified by the lead agency
Transition Coordinator is a term used by
MFP programs across the country.
Potential Transition Coordinators
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Managed Care Organization Care
Coordinator
Lead agency case manager
Another professional designated by the
lead agency. This professional needs to
meet the minimum qualifications of an
RSC
Transition Coordinator
Responsibilities
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Facilitate person centered transition
planning
Understand demonstration services and
other community services/supports and
how to access
Collaborate with person’s existing
supports
Transition Coordinator
Responsibilities, cont.
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Explore and identify housing options
Inform participant of their rights
Assist with preparation of needed
documentation
Help create 24-hour emergency back-up
plan
Communication with DHS and
Transition Coordinators
DHS
 Receive forms
 Determine eligibility
based on criteria
 Inform designated
County/MCO
contacts of eligible
participants
Transition Coordinators
 Complete informed
consent with eligible
participants
 Forward signed
Informed Consent to
DHS
 Notify DHS about
discharge plans and
successful transitions
Purpose of Communication
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Alert county of eligibility
Currently there is no eligibility type in MMIS for
Moving Home MN
DHS must receive notification of transition date
to enter into MMIS
Tracking and referral for 90 day follow up to 5
years
Tracking of housing type for enrollment changes
Demonstration requires follow up and evaluation
Meet Ellen
Olmstead: Housing as a Continuum
Institutional
Most restrictive
Least integrated
Dependent
GOAL
Community
Least restricted
Most integrated
Independent
Factors impacting choice
Individual-based
• Preferences
• Level of support needed
• Resources (income and
support)
Community-based
• Availability of options
• Availability of
supports
• Affordability
How did Ellen Move Home?
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Person Centered Plan
DD waiver services
Moving Home MN Demonstration and
Supplemental Services
– not otherwise covered by the state’s HCBS waivers or
the State Plan
– Support participants in transition
– Assist them in developing and maintaining stability in the
community
– Services work in conjunction with HCBS waivers and
state plan services
Person Centered Plan Components
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Focus: What’s important to the person? What’s
important for the person to keep them healthy
and safe?
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Individualized
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Risk Mitigation and emergency back up plan
Ellen’s Person Centered Plan
– Strategies for managing her mood and
periodic aggression
– Consultation and Collaboration
– 1:1 staffing in community through waiver
Supportive Living Services (SLS)
– Door alarm so staff/family know when leaves
– YMCA membership for regular light workouts
(accompanied by staff) to assist with anger
management
Risk Assessment and Mitigation
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Required components of the demonstration
– Assessment of risks associated with
community living for each individual
– Plan to mitigate the risks
– Acknowledgement of the risks and the plan by
the person, planning team members and
others
Risk Mitigation Plan Factors
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Community
Connectedness
– Family & Friends
– Leisure/Social
Activities
– Financial
– Self-advocacy
Access
– Transportation
– Employment
– Informal support
network
– Paid supporters
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Health and Medical
Safety
– Emergency Back-up
plan
– Medications
– Contact information
– Mental Health History
– Substance Abuse or
Use
– Critical Dependencies
Moving Home Minnesota Services
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Can be utilized with Home and Community
Based Service waivers and state plan services
Also available to those under the age of 65 in
lieu of a waiver
Demonstration and supplemental services
available to person for 12 months after transition
Demonstration and Supplemental
Services for All Populations
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Transition Planning and Transition Coordination Services
Comprehensive Community Support Services
Pre and Post -Discharge Case Consultation and
Collaboration
Night Supervision
Environmental modifications
Personal emergency response systems
Durable Medical Equipment and Assistive technology
Non-medical transportation
Membership fees (Supplemental)
Tools, clothing and equipment (Supplemental)
Demonstration and Supplemental
Services for Specific Populations
Ages 0-21
 Psychoeducation
Services
 Respite Services
 Youth Assertive
Community Treatment
Ages 65+
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Caregiver Education
Under Age 65
 Certified Peer Specialist
(CPS)
 Supported Employment
Services
Changes in Enrollment
Changes in enrollment in Moving Home Minnesota
can occur when:
 Person leaves qualified residence
 Person returns to an institution (suspension)
 Demonstration period ends (12-months postdischarge)
 Participants decides to end involvement
Re-institutionalization
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Less than 30 days
- Remains on Moving Home MN
More than 30 days
- Moving Home MN services are
suspended until the participant returns to
the community
Follow Up and Evaluation
Data from MFP states are part of a national
evaluation conducted by Mathematica
 Each participant will receive face-to-face
surveys and follow-up by Vital Research
regarding services
– Prior to discharge
– At 11 months, and
– At 24 months
 Participants will be able to receive follow up calls
every 90 days for up to five years
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Summary
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Moving Home Minnesota Goals
– Simplify and improve effectiveness of
transition services
– More consistent individualized approaches to
HCBS to better serve those with complex
needs
– Increase stability by strengthening community
connections
– Decrease reliance on institutional care
Questions
[email protected]