ADA: Americans with Disabilities Act, Title II
The ADA is a federal civil rights law prohibiting discrimination against people with disabilities in employment, public services, and private enterprises. Title II, referenced in the Settlement Agreement, prohibits discrimination in all levels of governmental services. 42 U.S.C. §§ 12131-34. See https://www.ada.gov/law-and-regs/ada/ for the full text and more information.
ASAP: Aging Services Access Point
The ASAPs are regional entities operated by non-profit entities that provide screening, evaluation, and services to older adults, with funding and oversight from the Executive Office of Elder Affairs (EOEA). ASAPs employ CTLP teams, which visit people in nursing facilities to talk about community options. Find your ASAP!
BH CP: Behavioral Health Community Partners
BH CPs support individuals 18 and older who are in a nursing facility, and have a positive Level II PASRR determination of SMI, with identifying and accessing an array of community-based services. See Nursing Facility Bulletin 180 for more detailed information.
Behavioral Health Services
Services provided to people with behavioral health disabilities. The Settlement Agreement focuses specifically on specialized services and behavioral health services available in the nursing facility that may help people develop skills, engage in community activities, and support transition to the community. For more information on services see Nursing Facility Bulletin 186.
Case Management Services or Care Coordination
A service provided to nursing facility residents which assesses the individual’s needs; develops, coordinates, and monitors person-centered and transition plans; makes service referrals; and coordinates and monitors the delivery of community, transition, and specialized services. Nursing facility residents should receive in-person visits from case managers at least monthly and should also be able to call their case manager whenever they need help.
CTLP Team: Community Transitions Liaison Program
The program that provides in-reach, informed choice, and transition planning services to assist people with disabilities in nursing facilities to learn about, engage with, access, and transition to community settings. To find your CTLP team, nursing facility residents should call their ASAP and ask for a visit.
Find your ASAP!
Cultural and Linguistic Competency
Culturally and linguistically appropriate services (“CLAS”) reduce health disparities and achieve health equity by respecting the individual’s race, ethnicity, culture and linguistic preferences. The Agreement specifically references the CLAS Standards, available here: https://thinkculturalhealth.hhs.gov/clas/standards.
DDS: Massachusetts Department of Developmental Services
https://www.mass.gov/orgs/department-of-developmental-services
The Department of Developmental Services, as the State Developmental Disability Authority, provides supports for individuals with intellectual and developmental disabilities, including Autism Spectrum Disorder, to enhance opportunities to become fully engaged members of their community.
DMH: Massachusetts Department of Mental Health
https://www.mass.gov/orgs/massachusetts-department-of-mental-health
The Department of Mental Health, as the State Mental Health Authority, assures and provides access to services and supports to meet the mental health needs of individuals of all ages, enabling them to live, work, and participate in their communities.
DMH Transition Case Management
The DMH Transition Case Management Team are DMH case managers assigned to nursing facility residents who have been determined to have PASRR SMI and to need nursing facility services for up to the next 90 days (“90-day determination”). The case manager is responsible for ensuring the provision of all specialized services and for supporting the resident’s transition to the community. See Nursing Facility Bulletin 180 for more detailed information.
DMH GLE: DMH Group Living Environment
DMH residential settings that provide a clinically oriented environment and structure with onsite staff. The setting provides increased treatment and engagement interventions to enable the individual to develop the skills necessary to live in a more independent setting. Different GLEs have different levels of staff with different skills, such as medical, nursing, and behavior training.
EOEA: Massachusetts Executive Office of Elder Affairs
https://www.mass.gov/orgs/executive-office-of-elder-affairs
The Executive Office of Elder Affairs provides quality aging-related resources, tools, and support through a network of regional non-profit agencies and municipal agencies across the state. The Agency partners with providers, caregivers, and the 1.7 million older adults in Massachusetts to help individuals live and thrive throughout the aging process.
EOHHS: Massachusetts Executive Office of Health and Human Services
https://www.mass.gov/orgs/executive-office-of-health-and-human-services
The Executive Office of Health and Human Services is comprised of 11 social service agencies and the MassHealth program. EOHHS seeks to promote the health, resilience, and independence of the nearly one in every three residents of the Commonwealth they serve.
Home Modification
Several programs offer funding to physically modify an existing home to make it more accessible, including the Money Follows the Person Demo (MFP-Demo), and the Moving Forward Plan (MFP) waivers. Modifications may include grab bars in showers, ramps, door modifications, and other structural changes. The Settlement Agreement requires the State to transition 2,400 people over eight years, 700 of whom can be people transitioning from nursing facilities to their own or a family member’s home or apartment, with a major home modification (i.e., requiring funding in excess of $5,000).
Informed Choice
Individuals in nursing facilities have the right to make decisions in a way that offers their fullest participation in decision-making possible. This includes, among others: opportunities to visit and engage in community programs, reasonable accommodation in choice-making for cognitive impairments or other challenges, consideration of the individual’s right to participate and act on their own behalf, and the right to consult with and include chosen supporters. <add once we have a policy> For more information see the informed choice policy.
In-reach
In-reach is the provision of information about community living and the provision of an informed choice process by knowledgeable case managers and agency staff in nursing facilities. In-reach activities include engaging with individuals to ascertain their strengths, needs, and preferences concerning transition; providing information and education about transition options; offering opportunities to visit community programs and service providers, including arranging for transportation to community settings; offering opportunities to meet with peers and families who have transitioned and arranging such meetings, as applicable; and addressing barriers and concerns about transition, including sociocultural barriers to transition (e.g., barriers related to varying perspectives about illness or fears and concerns about medications).
Medicaid Waiver
Massachusetts’ Medicaid agency, MassHealth, offers several programs that provide home and community-based services. The most important of these programs that help people move into the community with services and supports under the Settlement Agreement include:
- MFP Demo
- MFP-CL
- MFP-RS
If an individual applies for waiver services and is denied, they can appeal. Click here for more information.
MFP Demo: Money Follows the Person Demonstration Program
The MFP Demo provides a range of services and supports that help elders and people with disabilities move from facility-based care, and specifically nursing facilities, to the community. The MFP-Demo services focus on one-time transition needs. More information on the specific services available here: https://www.mass.gov/info-details/what-are-the-mfp-demonstration-services
MFP Waivers: Moving Forward Plan Waivers
Home and community-based services (HCBS) waivers designed to help MassHealth-eligible persons move from a nursing facility or chronic disease, rehabilitation, or psychiatric hospital back to their community. The MFP waivers include a wide range of community-based services, including case management, employment, respite, therapies, medical and nursing supports.
The two MFP waivers are:
- MFP Residential Supports (MFP-RS) waiver – for people who need supervision and staffing 24 hours a day, seven days a week in a provider-operated residence.
- MFP Community Living (MFP-CL) waiver – for people who can move to their own home or apartment or to the home of someone else and receive services in the community.
More information on specific services available here: https://www.mass.gov/info-details/moving-forward-plan-mfp-waivers
NF: Nursing Facility
Nursing facilities are institutions certified by a state to offer 24-hour medical and skilled nursing care, rehabilitation, or health-related services to individuals who do not require hospital care. For more information see https://www.macpac.gov/subtopic/nursing-facilities/
PACE: Program of All-inclusive Care for the Elderly
PACE is an integrated health care program that provides older adults access to all services covered by Medicare and MassHealth so that they can live safely in the community instead of a nursing facility. More information on specific services available here: https://www.mass.gov/program-of-all-inclusive-care-for-the-elderly-pace
PASRR: Preadmission Screening and Resident Review
The Level I PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether may have Serious Mental Illness (SMI) or Intellectual Disability (ID) and whether they meet the clinical conditions for nursing facility admission. This is called a “Level I screen.”
Those individuals who have a positive Level I screen are then provided a comprehensive assessment, called “Level II” evaluation. The evaluation determines if the nursing facility is the most appropriate setting, if the individual needs specialized services, and if the proposed nursing facility placement is qualified and capable of providing those services.
People with a positive Level II PASRR with SMI get extra services under the Settlement Agreement, including specialized services and case management.
For more information about PASRR generally, see: https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html
PASRR SMI: Preadmission Screening and Resident Review, Serious Mental Illness
PASRR SMI has a federal definition with a more specific standard than mental illness or even serious mental illness as defined by the federal government, the Commonwealth, or professional associations. To have PASRR SMI a person must meet all four criteria:
- Have a diagnosis or suspicion of a major mental illness.
- Either have no dementia, or, if they do have dementia, the mental illness must be more serious than the dementia.
- Have intensive psychiatric treatment for mental illness in the last two years.
- Have functional limitations in major life activities within the past three to six months related to mental illness.
In Massachusetts, people in nursing facilities must be screened for PASRR SMI prior to admission to a nursing facility. If they have PASRR SMI, they must be re-screened annually for as long as they are in the nursing facility. People with positive PASRR SMI are entitled to receive extra services, called specialized services, while in the nursing facility.
Rental Subsidy
Federally or state funded programs that help pay a portion of, or the full monthly, rent. Some “vouchers” must be used at a specific housing unit, while others can be used anywhere. The Settlement Agreement will make additional rental subsidy options available to people in nursing facilities to help them pay for housing.
Residential Services and Supports
Services that include provider-operated homes in the community plus an array of support services necessary to allow individuals with complex needs in nursing facilities to live in integrated settings in the community. Residential services and supports are provided by EOHHS through its Moving Forward Residential Waiver program (MFP-RS).
For some people with disabilities in nursing facilities who do not need this level of assistance, but do need an affordable and accessible residential setting, residential services and supports include a housing subsidy for an accessible and affordable living unit and a service coordinator/case manager who locates and arranges the housing unit. This type of residential services and currently is provided by EOHHS through its Moving Forward Community Living Waiver program (MFP-CL), as well as through DMH’s supported housing programs.
Both waiver programs and DMH’s programs have a fixed capacity, which must increase over the course of the eight-year agreement to allow all qualified persons with disabilities in nursing facilities to live in integrated settings in the community.
SCO: Senior Care Options
Senior Care Options (SCO) is a comprehensive health plan that covers all of the services normally paid for through Medicare and MassHealth. This plan provides services to members through a senior care organization and its network of providers. It combines health services with social support services by coordinating care and specialized geriatric support services, along with respite care for families and caregivers. SCO offers an important advantage for eligible members over traditional fee-for-service care. There are no copays for enrolled members enrolled. More information on specific services available here: https://www.mass.gov/senior-care-options-sco
Specialized Services
For people who have a positive PASRR Level II (see above), nursing facilities must provide extra services to address specific needs related to a person’s mental illness. Services are identified at the Level II evaluation and must be provided in the frequency, intensity, and duration needed to treat the individual’s needs.
Massachusetts’ specialized services for people with SMI include:
1. Psychiatric evaluation and psychotherapy services
2. Neuro-psychiatric evaluation
3. Substance use disorder treatment services for the provision of methadone, buprenorphine, buprenorphine/naloxone, or naltrexone
4. Clubhouses
For people with a positive PASRR Level II, any behavioral health and rehabilitative service needs identified by a comprehensive assessment must also be met.
Transition
Transition is the process of moving from the nursing facility to the community. CTLP teams, BH CPs, and DMH case managers can all help with transition. Everyone in a nursing facility should have case managers available to help with transition.
Transition activities include referring nursing facility residents to state agencies, community programs, service providers, housing organizations, and other community supports; assisting in locating, applying for, and qualifying for community services and housing options; assisting individuals who are initially deemed ineligible for public or subsidized housing in appealing those determinations and/or referring those individuals to housing advocacy organizations such as legal services programs, as applicable; participating in transition planning; coordinating activities necessary to accomplish a successful transition to the community; and helping residents obtain and/or providing small amounts of funding to obtain items necessary to facilitate transition (e.g., a government-issued identification document).
For purposes of the Settlement Agreement, the State counts as a successful transition once an individual has moved to a community setting. The Commonwealth must transition at least 2,400 people over eight years.