1. Money Follows the Person (MFP) Demonstration Identification of and Outreach to Nursing Home Residents Project Providing Objective Information on home and community–based services to Nursing Home Residents Christine Duffy MFP Program Coordinator St. Mary’s Healthcare System Money Follows the Person

2. New York State Department of Health has contracted with St. Mary’s Healthcare System as a designated Local Contact Agency (LCA) to implement the MFP project in the New York City Region. The purpose of MFP is to provide certain nursing home residents, identified by the Long Term Care Minimum Data Set (MDS), with objective information on home and community-based services, that may be available to them. MFP staff then can provide additional assistance with discharge planning, as requested by the resident, their families and/or the social work staff of the nursing home.

3. The DOH provides MFP staff with a list of nursing home residents who may be good candidates to transition back to the community Determination is made based on the RUG score on the nursing home MDS. Residents and / or their family can let the social worker or MFP staff know they would like to receive information on available community based services. Social work staff at a nursing home may make Section Q referrals based on the resident’s answers in Section Q of the MDS. Resident’s can accept OR decline visit.

4. If a resident/family is considering transitioning out of a nursing home, a MFP staff person meets with them (and the family) to discuss their care needs and possible community based service options. If the individual (and family) is interested in pursuing discharge, a referral is made to the nursing home discharge planner. At the request of the resident/family, MFP staff can attend discharge planning meetings to further discuss available community based options and how to access them. MFP staff can also follow up on referrals made to community resources if the resident/family requests.

5. Adult Day ProgramsAssisted LivingHomecare OptionsMeals/Nutrition OptionsHousing Utility/Weatherization Assistance Assistance With Household Chores Transportation Resources Specific To Their Community Depending on their specific needs, participants may receive information about:

6. A referral indicating a resident’s interest in transitioning is made to the nursing home discharge planner. Information provided to the resident/family is also shared with the discharge planner/social worker. At the resident’s request, MFP staff will collaborate with the discharge planner & follow up on any referrals made. The goal is to educate the resident and family about potential community based services that may be available to them & assist them in the process of transitioning back into the community.

7. Meeting with or receiving information from MFP representatives will not affect a resident’s status at the nursing home in ANY way. If a resident decides to remain in the nursing home, he or she can always ask to meet with MFP at a later time should they want to reconsider discharge from the nursing home.

8. Residents receive objective information about community based services and long term care options that may be available to them and they decide to remain where they are. Families receive the objective information and keep it for consideration at a later time. Residents successfully transition from the nursing home back into the community with the necessary community based services in place.

9. How long does the process take? The length of time the process takes for each resident varies depending on their individual needs and the sophistication & availability of the services required. What are some of the potential barriers to a successful transition? Lack of appropriate, affordable housing. Availability of community based and homecare services The person may not be eligible for the program or service they are interested in receiving.

10. Does MFP replace the nursing home’s discharge planning? NO -- MFP works as an adjunct to the discharge planning provided by the nursing home. How is MFP different than NHTD? MFP provides objective information about a wide variety of community based services and long term care options in each of the counties it serves. NHTD – Nursing Home Transition and Diversion is a specific Medicaid Waiver program that provides additional services (waiver services) in addition to traditional services funded by Medicaid (state plan services).

11. 29-01 216 Street Bayside, NY 11360 MAIN PHONE: (718) 281-8800 St. Mary’s Healthcare System PHONE: (718) 281-8752 FAX: (516) 240-6436 EMAIL: cduffy@stmaryskids.org@stmaryskids.org Christine Duffy, Program Coordinator Money Follows the Person Demonstration Project This document was developed under grant CFDA 93.791 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government.