In-reach, informed choice, and transition planning
Everyone gets to make a choice! Everyone in the nursing facility gets to make an informed choice about where to live, and whether to move home with support.
Class members will receive information and opportunities to learn about community options, help in leaving nursing facilities, and special services while in nursing facilities to support transition to the community.
Case management services should be available in a person’s preferred language and should present options for returning to home communities. Services should include identifying specific housing options, including Medicaid Wavier applications where needed. Services should also include, where needed, help obtaining identification, reasonable accommodation requests to address criminal history, and other creative solutions to address barriers to returning to the community.
Case management services
Everyone gets someone! Everyone in the nursing facility gets some kind of case management service.
Community Transitions Liaison Program (CTLP): CTLP TEAMS come from the local Aging Services Access Point agencies (ASAPs) and are available at every nursing facility. They visit each nursing facility at least once per week, nursing facility residents can ask questions about moving to the community, receive assistance in visiting community alternatives, and meet with other people who have already moved to the community. CTLP teams help address any concerns about moving or living in the community. The CTLP teams receive special training about how to support people to make their own informed choices. CTLP teams are available to any adult living in a nursing facility who doesn’t have another case manager, even people without Medicaid.
MFP DEMO (a special Medicaid-funded program) offers case management for people who use the MFP Demo and other Medicaid Home and Community-Based Services (HCBS) Waiver programs to find housing and arrange services in the community. They can also do all the things that the CTLP teams do.
DMH provides case managers who help people with serious mental illness (SMI). These case managers help people identify and arrange community services, and special services only available to people with SMI. They can also do all the things that the CTLP teams and MFP Demo case managers do.
Coordinated behavioral health services
Class members with PASRR SMI must receive regular evaluations and behavioral health care coordination through Behavioral Health Community Partners (BH CPs). BH CP Care Coordinators meet in person with eligible people with SMI to make a behavioral health care plan and make sure needed services are actually are provided. For example, eligible people with SMI may leave the nursing facility to go to a Clubhouse, where there are daily activities, socialization, and recreation, and information about life skills, housing, health, and wellness.
If someone with PASRR SMI applies for a Medicaid Waiver and is denied because they cannot be safely served in the community, the person will be referred to DMH to see if extra services could help with safety concerns. Legal Services attorneys can also help appeal denials.
Residential Services and Housing Support
The Settlement Agreement offers new community housing options in a variety of settings.
Over the next 8 years, the Commonwealth will add community housing options to help class members transition to the community. There will be more places for:
- People who want to live in a staff supervised shared living environment like a group home (Moving Forward Plan-Residential Supports (MFP-RS), or DMH Group Living Environments (GLEs)).
- People who want to live in their own home but need both housing and services (Moving Forward Plan-Community Living (MFP-CL), Rental Subsidy Program, subsidized housing targeted to class members with both mobile and project-based vouchers).
- People who already have housing but need physical changes to the home (home modifications up to $50,000 for MFP-CL participants or MFP Demo enrollees).
- Older adults eligible for supported housing through managed care programs such as PACE or Senior Care Options (SCO).
Cultural and linguistic competency
Including training for staff, transition options in home communities, and supported decision making.
Metrics
For information on progress see the Data Dashboard (Coming Soon!).
Transitions and Timeframes:
A total of at least 2,400 people living in nursing facilities will move to the community by the end of the 8-year Agreement, with interim transition targets.
- 20% (480) by the beginning of Year 3
- 50% (1,200) by the beginning of Year 5
- 85% (2,040) by the beginning of Year 7
Transitions should happen within specific time limits, and if they do not, there should be a good reason why not. The time limits are:
- Within 18 months for people moving to staff supervised group homes.
- Within 12 months for people who need help finding their own subsidized housing.
- Within 9 months for people returning to their own housing.
Building Housing Capacity
Over the course of the Agreement, the Executive Office of Health and Human Services (EOHHS) will add housing services and beds in a variety of settings, including at minimum:
- 400 MFP-RS Waiver services
- 200 DMH GLEs (with reasonable efforts to add 200 more)
- 595 MFP-CL Waiver services
- 320 Rental Subsidy services
- At least 120 home modifications that cost more than $5,000