1. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

2. 2 Goals Provide a context for discussing change in Pennsylvania’s Long Term Living system Provide key information for staff to support Enhanced Nursing Home Transition

3. Susan Reinhard Co-Director Community Living Exchange Rutgers University July 12,20063 Improving Access to LTC Options States are looking at best methods to avoid unwanted institutionalization –Managed Care (Arizona, Texas, New York) –Various Nursing Home Transition programs Nursing Home Transition programs –Large statewide programs (WA, NJ, Oregon) –State employees (NJ, WA) –Contracted organizations (CO) –Small programs for most challenging (SC, CT) –Locally based organizations (Centers for Independent Living, Area Agencies on Aging)

4. 4 The Pennsylvania Picture Three Imperatives to Balance the Long Term Living System in PA –Demographic trends –Consumer choice –Fiscal challenge

5. 5 Pennsylvania’s Progress Share of NCBS Waiver users has increased since 2002-03

6. 6 Enhanced Nursing Home Transition Strengthened collaborations Active engagement of AAAs and DPW NHT partners Incentives for agencies to achieve successful transitions Special funding for Transition Services Unified Data Tracking MDS Data LTL Counseling

7. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

8. 8 Minimum Data Set (MDS) Reports

9. Front Door Bi-Monthly Admissions Run Date:8/1/2006 County:Lancaster Total Residents:163 Facility Name MA Number <=30 Days 31 to 90 Days Long Term UN- CER TAIN DEM- ENTIA Under 60 Over 60Total AUDUBON VILLA 100750738 000400031033 BEVERLY MANOR OF LANCASTER 101551917 000100010011 BRETHREN VILLAGE 100126248 000310411066 CALVARY FELLOWSHIP HOMES, INC 000745243 000101132055 TOTAL26184475506157163

10. Provider Name First Name M I Last Name AGEAGE <= 30 D A Y S 31 To 90 DAYS LONGTERMLONGTERM UNCERTAINUNCERTAIN DEMENTIADEMENTIA < 60Tracker #Referral AUDUBON VILLACarsonBusses88000100 AUDUBON VILLAEarl LeeByrd85000100 AUDUBON VILLAPattyCakes90000110 Run Date 08/01/2006 County: Lancaster

11. 11 Lancaster MDS Information Number of people identified: 163 Number of Nursing Facilities listed: 28 Number of short term: 44 Number of long term: 44 Number of uncertain discharge: 75 Number of people with a dementia-type diagnosis: 50 Number of people Over 60: 157 Number of people Under 60: 6 Number of people in each facility: Audubon Villa – 3 Short Term – 0 Long Term – 0 Uncertain - 3

12. 12 Unified Data Tracking Module has been created in OMNIA to collect transition data All agencies will use the same system Real time data collection to allow ready access to critical information

13. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

14. Comparison of working with a newly admitted resident vs. long term resident

15. Susan Reinhard Co-Director Community Living Exchange Rutgers University July 12,200615 Myth: Most People in Nursing Homes Need to be There Those who resist change say: “People in nursing homes today are too frail to live in the community. Only a few of them can really leave.” Fact: For every person in a nursing home who needs assistance with 3 or more activities of daily living, there are 1.83 people living in the community who have the same level of disability.

16. 16 Generalizations regarding newly admitted residents Overwhelmed by process that lead to NHP Informal support present and engaged Come from acute care or home setting Usually still have residence, material possessions Apprehensive

17. 17 Generalizations regarding long term residents Informal supports have relaxed or gone away Loss of material possessions Resignation to institutionalization Dependent upon NH staff, schedule, supports May be in grief/loss cycle

18. Change = Loss = Grief Important factor is not that the change is good or bad, but that it is perceived as a negative event

19. 19 Kubler Ross (1969) Grief/Loss cycle –Denial –Anger –Bargaining –Depression –Acceptance

20. 20 Roller coaster ride of the grief/loss cycle

21. 21 Barriers to NHT Irrational fears/thoughts External influences/institutional bias Lack of supports Housing issues Lack of knowledge regarding availability of community services Ageism

22. 22 How to Address Barriers Differentiate between rational and irrational Express that consumer/informal supports have control/support Change the dialogue Challenge fears Develop support systems Be available Be supportive, not smothering Tout the success stories

23. 23 Windows of Opportunity Before informal supports dwindle Before material possessions are gone Before becomes resigned to institutionalization Before supports are developed inside the facility Before hope is gone

24. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

25. 25 Technical Assistance Roll-out Meetings Monthly Regional TA Calls NHT Technical Assistance Guide NHT Conference in October Regional Housing TA Meetings NHT E-mail Address: ra-nht@state.pa.us State Staff: –PDA – Tim Hoskins, (717) 783-6207 –DPW – Kim Kramer, (717) 787-8097

26. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

27. 27 Long Term Living Counselor Provide information and guidance to consumers Ensure that all options are explained fully Enable consumers to make informed choices about where and how they receive LTL services AAA NHT Responsible for transition services and supports to over 60 consumers; actively works with each consumer to complete a successful transition DPW NHT Partners Responsible for transition services and supports to under 60 consumers; actively works with each consumer to complete a successful transition Local Collaboration Shares knowledge, expertise, and resources to support successful transition; case conferencing around difficult transitions; other activates depending on local arrangements Coordination between LTL and NHT activities