1. Stakeholder Meeting October 1, 2013

2. Where We Started  A Mission  32 Nursing Facilities  A Plan Public Service Consultants (410)929-7258 2

3. What We Found Public Service Consultants (410)929-7258 3

4. Characteristics Of Good Peer Outreach & Support Staff  Peer Facilitators will have multiple roles including  Being an effective peer outreach & support staff member  Sharing personal experiences about institutional living and transition process;  Being an effective peer by building relationships with residents and NF staff  Being knowledgeable of community resources and supports  Being an active listener Public Service Consultants (410)929-7258 4

5. Outreach To Professional Stakeholders  Options Counselors and Options Counseling Organizations, Social Workers, Nursing Facility Staff, Health Care Coordinators, Baltimore City Ombudsman's Office Contact nursing facilities stakeholders and: Image Center (Living At Home Waivers)  Held 1 st one-on-one meeting with Image Center (Living At Home Waivers) in Fall 2012  Held 1 st information session with Ombudsman Program Spring 2013 Maryland Disabilities Law Center in Winter 2012-2013  Held informational session Maryland Disabilities Law Center in Winter 2012-2013 5 Public Service Consultants (410)929-7258

6. Peer Outreach Workflow Public Service Consultants (410)929-7258 6 Maintain schedule of NF actiivties; Citywide related opportunities to present MFP Work with Ombudsman to maintain and schedule networking opportunities to further the understanding about MFP and Peer Outreach and Support; Visits to NF events and/or activities; Knock before entering resident room; Announce who you are and why you are there; Leave MFP information and obtain resident info. Send introduction letter to NF Staff; Call and schedule 48 hours in advance of all site visits; Meet with nursing facility staff Nursing Facility Resident Information Ombudsman LTSS Tracking System

7. Peer Support Work Flow Public Service Consultants (410)929-7258 7 Remain plugged-in, updated and resource rich; Touch base with Options Counselor and LAH Waiver staff ; Review data in tracking system for accuracy; Remain current on changes to the NF that effect support needed for NF residents; Maintain two way communication to inform and learn about local updates in major changes to NF’s that effect Peer work (staff changes, NF closings, management changes, unmet resident needs, etc. Verify that resident has an interest in transitioning from NF; Discuss and indentify barriers to transition; Meet one-on-one with residents to discuss process and share perspective of transitioning and the possibility of community living. Identify opportunities for further support; Peers refer residents for peer support Make inquiry to Options Counselor, LAH Waiver and NF staff regarding residents that have expressed an interest in transitioning from NF’s; Call and schedule 48 hours in advance of all site visits to meet with NF residents; Professional Stakeholders NF Resident Information Ombudsman LTSS Tracking System

8. Outreach to Individuals  Key Elements of Outreach to Residents  Verify informal referral sources;  Identify and prioritize facilities with regard to scheduling;  Make referrals for Options Counseling and /or provide peer support; 8 Public Service Consultants (410)929-7258

9. Tools We Use PSC Internal Database Local & State Literature In & Out Peer Network Flyer Door Hangars MFP Maryland Public Service Consultants (410)929-7258

10. Outreach Opportunities  Outreach in group settings; strength in numbers;  Don’t underestimate “word of mouth”;  Baltimore City citywide presentation opportunities;  Mass marketing of MFP  Peer networking among residents and staff;  Some NF’s and stakeholders seem threatened;  Confusion among residents and professional stakeholders; 10 Outreach Challenges Public Service Consultants (410)929-7258

11. Support Opportunities  Coordinated support to multiple NF residents with same or similar barriers;  Coordinated, scheduled support to nursing facilities;  Increased participation among stakeholders to address principal barriers to transition;  Residents ambivalent about role of Peer;  Residents may not see support from Peer as tangible;  Decentralized support / Information overload;  Verifying results (outcomes and placement); 11 Support Challenges Public Service Consultants (410)929-7258

12. Lessons Learned  Cultivate relationships;  Clarify misinformation in writing when possible;  Capture everything in LTSS system;  Over communicate;  Ask case managers, counselors, stakeholders about residents already willing and waiting to transition from NF’s. Residents are waiting on us. (Smile) Chaos Cooperation Coordination Communication Collaboration