Nursing Facility Transition Grant - Narrative
1. Identification of Problems or System Issues
A. Background and Identification of Problems:
Providing long-term care options for older adults and persons with disabilities is expected to increase the strain on federal and state governments in future years. The Urban Institute (Parental Care at Midlife: Balancing Work and Family Responsibilities Near Retirement) reports that nursing home expenditures increased from $17.4 billion in 1970 to $84.7 billion in 1997, and Medicare payments for home health care increased 21 percent per year from 1987 to 1997.
Indiana has historically over-relied on nursing home care as the service of choice for older adults and persons with disabilities. Indiana has the highest ratio in the country of nursing home beds per 1,000 persons age 85 and over, as noted by the AARP Public Policy Institute. While Indiana's per recipient expenditures are below the national average, per capita expenditures are among the highest, illustrating that Indiana Medicaid serves a large number of individuals in more expensive, institutional settings. During Calendar Year 2000, the Resident Review component of Indiana’s Pre-Admission Screening Resident Review program revealed 997 individuals with developmental disabilities residing in nursing facilities.
As a result of this over-utilization of nursing homes, Indiana ranks low among states in the utilization and funding of home and community-based services (HCBS) waiver programs. Since aggregate nursing home expenditures total nearly $800 million annually, Indiana has been greatly challenged to find a balance between the funding of institutional or home and community-based programs.
B. Analysis of Strengths and Challenges:
Indiana's support system for the aged and persons with disabilities in the community has important strengths that will be the foundation for the grant projects. These include: 1) a well-designed community-based services program, the IN-Home Services Program; 2) Indiana's six Home and Community-Based Services (HCBS) waiver programs; and 3) its data management system for long term care services provided both in the nursing home and in the community.
In contrast to its reliance on nursing facilities, Indiana has received significant local and national recognition for its IN-Home Services Program. The Indiana Family and Social Services Administration (FSSA), through the Division of Disability, Aging, and Rehabilitative Services (DDARS), is the entity that administers the IN-Home Services Program. Started in July 1992, this program brings together funding from the Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE), Title III of the Older Americans Act, the Social Services Block Grant, the Older Hoosiers Account, six HCBS Waivers, the United States Department of Agriculture Meals program and local and private funds.
During FY 2000, these funding streams provided services to 107,722 older Hoosiers and persons with disabilities. This includes 12,338 persons served through Indiana’s CHOICE program and 4,904 served through the five Medicaid Waivers in place at this time. These persons were all at risk of losing their independence.
In 1997, the Hudson Institute reviewed the Indiana program in its publication, The Cost Effectiveness of Home Health Care: A Case Study of Indiana's In-Home/CHOICE Program. The authors positively reviewed the In-Home/CHOICE program as an example of a well managed, cost effective home care program. They also state that there is strong evidence that home care programs such as CHOICE can play a vital role in meeting consumer needs and preventing institutionalization.
Indiana administers six HCBS Waiver programs. These waivers target older adults and persons with disabilities, persons with developmental disabilities, persons with autism, children who are medically fragile, and individuals with traumatic brain injury. The population that can be served by each of these waivers is 2,500 (Aged and Disabled Waiver); 2,933 (ICR/MR Waiver); 200 (Autism Waiver); 350 (Assisted Living); 150 (Medically Fragile Children's Waiver), and 200 (Traumatic Brain Injury Waiver). Plans are underway to fund additional slots for the Aged and Disabled Waiver (822 slots for State Fiscal Year 2002, and 813 slots for State Fiscal Year 2003). The Medicaid Waiver for Persons with Developmental Disabilities has been increased to serve an additional 2,282 persons in the first year; an additional 722 persons the second year; and a further addition of 111 persons the third year. This will bring the total availability of persons with developmental disabilities to be served through the Medicaid Waiver to 5,649.
In a proposal to Governor Frank O’Bannon on February 15, 2000, the CHOICE Board focused on six initiatives to enhance, or expand the long-term care options for older adults and individuals with disabilities, and utilize the community and in-home services. These initiatives are based on the principles of independence, quality, dignity, privacy, and personal choice. The six initiatives developed by the CHOICE board are: adding Assisted Living to the array of long-term care optional services; adding Adult Family or Foster Care to the array of long-term care optional services; adding Adult Day Health Services to the array of long-term care optional services; expanding pre-admission screening assessment and case management; expanding the Indiana Long Term Care (insurance) program; and identifying funding options.
In 2000, Indiana applied for an Assisted Living Medicaid Waiver and amended the Aged and Disabled Medicaid Waiver to enhance Adult Day Services. In addition to the new Medicaid Waiver request to coordinate services for persons with developmental disabilities, Indiana has also submitted a State Plan amendment to provide targeted case management services to this population. Furthermore, the Indiana Long-Term Care Insurance provisions have recently been offered as a benefit to state employees.
In 1998, the National Governor's Association highlighted Indiana for its use of interagency partnerships and innovations in preparing for the aging baby boomer generation. According to Transitions: States Prepare for the Aging of America, written by Jeannette M. Herick Ph.D., Indiana's approach to service delivery results in an individualized person centered planning approach, whereby the entire well-being of the client and caretaker is considered in care planning. Older adults and individuals with disabilities can contact the Area Agency on Aging (AAA) serving their area through a statewide all ages toll-free telephone number (1-800-986-3505) to access in-home and community-based services.
Indiana also is building a comprehensive quality assurance program. Recognizing the importance of quality assurance improvement, DDARS recently established the Bureau of Quality Improvement Services under the leadership of Chris Newman. This Bureau is specifically charged with the development of standards, quality improvement, and data analysis to assure that consumers receive high quality services and that any deficits in services are corrected.
In a statewide demonstration project funded by the Robert Wood Johnson Foundation, the State of Indiana, AAAs, vendors, consumers, and Indiana University researchers worked together to use Total Quality Improvement techniques to improve the delivery of community-based long term care services. The resulting Quality Improvement Process (QIP) is now used by all 16 AAAs. It places an emphasis on measuring consumer choice, consumer satisfaction and numerous other domains and, while providing consumer confidentiality, offers specific feedback to home care providers to improve the services to consumers.
Another strength of the Indiana IN-Home Services Program is its data management system. Information for persons served through the CHOICE and HCBS Waiver programs is available from the INsite system maintained by DDARS. The data tracking begins with data entry by case managers. Case managers enter information including demographics, functional assessments, level of care, family and community support systems, limitations in activities of daily living (ADLs) and instrumental ADLs, nutrition risk assessment, consumer goals, planned services, costs and frequency of services, funding sources, initiation and stop dates, quality assurance measures, and other data elements. The data is then electronically transmitted to the State office.
Integrated into Indiana's long-term care program is the Pre-Admission Screening (PAS) program enacted by the Indiana General Assembly in 1983. A well integrated PAS program is imperative to ensure that nursing home placements are only for those persons who have care needs that are best met through this level of care. The PAS process is the beginning point for in-home and community based services and nursing home placement. In 1989, the federally enacted Pre-Admission Screening/Resident Review (PAS/RR) program was implemented in Indiana and assures that persons with a major mental illness, or a developmental disability/medical condition, who apply to or are residents of Medicaid certified nursing facilities, have their needs met appropriately. However, one of the challenges faced by the PAS/RR system is that waiting lists for Medicaid HCBS services has resulted in the inability to make community-based services available for those who could otherwise have had their needs met outside of the nursing facilities. (See discussion of waiting lists, below, for a more detailed explanation of this challenge.)
The major challenge that Indiana faces in its IN-Home Services Program lies in providing services to an increasing number of the elderly and persons with disabilities in Indiana. The Indiana University Center for Law and Health (Projecting the Need for Community-Based Long-Term Care and Other Supportive Services in Indiana, July 1998) found that there are 978,099 people in Indiana over age 60. More than 240,000 of these persons experience some limitation in two or more ADLs such as bathing, dressing or walking. In addition, 136,000 Hoosiers below age 60 also experience some limitation in these activities. More individuals wish assistance from community and in-home services programs that offer an array of services to enable older persons and persons with disabilities of all ages to live independently in their homes and communities.
Another challenge Indiana faces is that there are waiting lists for five of the HCBS waivers in the state. Because Indiana's waiver programs operate on a first-come and first-served basis, Medicaid waivers are not immediately available to individuals who would otherwise be able to transition out of nursing facilities if their functional status or health status improves. In addition, individuals who are newly in need of services and whose needs could be met in either a nursing home or home care setting may be unnecessarily institutionalized because of a lack of waiver funds for community alternatives.
The state faces a challenge to a diversion project in the present state PAS law. Under the current system, the opportunity to divert persons from nursing home placements by coordinating alternative services and care is often lost due to the many exceptions in the state PAS law. These exceptions often allow hospital discharge planners to immediately place discharged patients in nursing facilities because the state allows pre-admission screening to take place up to 30 days after persons have been admitted to nursing facilities. In these instances, the system is not actually a "pre-admission" but a "post-admission'" screening process.
Lastly, the state faces a challenge in establishing a system to enhance the collaboration between case managers and hospital discharge planners. While cooperation exists, more timely means are needed to identify persons who can return to their communities after a hospitalization rather than being transferred to a nursing facility. For individuals who need nursing facility placement, a system is needed to follow the progress of these persons and assist in their transition to the community.
C. Problem Analysis:
In Indiana, nursing homes provide a disproportionate share of long-term care for older adults and individuals of all ages with disabilities. During 1999, of persons receiving long-term care services funded through Medicaid, 92.1% were cared for in nursing homes, while only 7.9% of this population received in-home and community based services.
The historical reliance on institutional placements in Indiana is coupled by a very low occupancy rate in nursing facilities. In 1996, Indiana ranked 9th highest in the U.S. in excess nursing home capacity. In January 1999, figures from the Indiana State Department of Health showed that only 77.77% of the beds in 590 nursing home facilities in Indiana were occupied - an occupancy rate similar to the 77% in 1998 which placed Indiana at 45th in the United States in occupancy rate.
Even though Indiana has a low occupancy rate for nursing facilities, this placement continues to be the primary means for persons with significant disabilities to receive services. The challenge is to shift this balance of service provision to reflect the choices made by the individual. Systems will be altered to reflect the wishes of individuals to receive the service of their choice in the location of their choice.
2. Project Description and Methodology
A. Goals and Objectives:
The primary goal of this grant project is to create system and policy changes that will impact the way Hoosiers receive long-term care services. Indiana will spend the first year of the grant planning and designing these changes, to be implemented during years two and three when at least 60 persons will be transitioned or diverted to the community living arrangements of their choice. This will be a first step to refining the system and learning how to best address the concerns of consumers, enhancing provider capacity, and outreaching to communities for local support and collaboration to achieve successful transition.
Some of the issues to be addressed during the first year of planning include: identification of persons for transition and diversion, utilization of targeted case management practices, establishment of local coalitions to direct transition and diversion projects, education and outreach, utilization of fiscal intermediaries, establishment of training curriculum for staff, consumers and providers, establishment of evaluation protocols, and involvement of Independent Living Centers.
The second and third years of the grant will concentrate on transitioning at least 40 individuals from nursing homes, and diverting at least 20 persons from nursing home placements. It is anticipated that fifty percent of participants will choose to return to their homes or other individual settings and be provided with in-home services. It is further anticipated that the remaining individuals will choose a residential setting, e.g., assisted living. Because Indiana’s five Medicaid Waiver programs operate on a first-come, first-served basis and there are waiting lists for the two major waivers (the Aged and Disabled waiver and the Developmentally Disabled waiver), it is anticipated that grant funds will be used to support service costs for these 60 individuals for an average of 12 months each over the life of the demonstration. Individuals will be assisted in applying for waiver services immediately upon being identified for participation in the pilot, and if the grant funds allocated as service dollars are more than adequate to serve the 60 people because waiver slots do become available, the number of people targeted for transition can be expanded.
Indiana is also applying for a Community-Integrated Personal Assistance Services and Supports (Community PASS) grant. If successful in obtaining these Community PASS grant funds, it is projected that approximately ten to twenty persons transitioning to community settings will choose consumer-directed personal attendant care services. Additionally, FSSA is submitting a grant request under the Real System Change process. These grants will all have significant impact upon Indiana’s current system as well as the specific individuals returning to their communities. The overall project management by FSSA, under the direction of the office of Governor Frank O’Bannon, ensures coordination of these separate grant activities.
In order to achieve successful transition/diversion projects, a number of barriers will be addressed:
- First, many residents who are returning to their communities need appropriate housing. Securing funding for housing costs for these persons will be addressed further in the grant application.
- Second, specialized case management is needed to facilitate the transition of residents to the community. The process will include person centered planning, development of the individualized care plan, transition into the community, quality assurance, and monitoring of health and safety issues.
- Third, local collaboration will encourage nursing home providers to broaden their scope of services into their communities. Participating nursing homes may be able to recognize incentives in providing community-based services.
- Fourth, the transition process involves current residents of nursing homes. Individuals residing in nursing facilities longer than six months have typically begun the "settling in" process. It becomes exponentially more difficult to relocate these persons as longer time periods are spent at facilities. Therefore, length of stay will be a factor in identifying persons to participate in the direct services projects. However, individuals who have resided in a nursing home for extended periods of time will not automatically be excluded; both populations will have an opportunity to be relocated.
- Fifth, the diversion portion of this project will include persons who are about to be transferred from a hospital to a nursing facility. Hospital discharge planners are often under considerable pressures to work with these persons. Local coalitions will include and collaborate with hospital discharge planners to determine individuals suitable for diversion. Education concerning community-based services, rather than nursing facility placement, will be emphasized in this process.
- Sixth, determining service eligibility for Medicaid waivers and initiating services is a time consuming process. Service eligibility must be simplified to successfully carry out transitions and diversions. Some success has already been accomplished in shifting increased decision making to the local level. Further, decentralization will occur as increased training and quality assurance processes are put in place.
- Seventh, individuals who are not yet Medicaid eligible, but who are likely to be Medicaid eligible within a short time span, pose additional challenges. These issues include the length of time to determine eligibility and spend down requirements, and to identify sources of home care funding outside of the Medicaid system. The Community Choice Commission and relevant state agencies will address these issues.
- Eighth, peer counseling has been available on a very limited basis. This grant opportunity will facilitate greater linkages to Independent Living Centers (ILCs) to enhance consumer choice and direction and peer counseling opportunities. The companion grant proposal being submitted by the ILCs for Indiana’s Nursing Home Transition project is seen as an important vehicle for this enhancement.
Another challenge to a successful transition or diversion project is the ability to assure that funds will be available to continue the project after the grant funds have been exhausted. Indiana currently has six approved Medicaid Waivers (Aged and Disabled; ICF/MR; Autism; Medically Fragile Children; Assisted Living; and Traumatic Brain Injury). The continuation of services to individuals after the grant demonstration period will involve the use of the six approved waiver programs or other state/local funds. This demonstration period will enable Indiana to analyze, study and focus on the most appropriate, cost effective and innovative methodology to be used for future funding and to make necessary changes to state funding streams and HCBS waivers.
Finally, successful transition cannot occur without an adequate, affordable, and safe living environment. The goals of the transition and diversion projects are to enable each person returning to the community to reside in the housing environment of his/her choice. For those persons who may be able to return to their homes when provided with support services, every effort will be made to accommodate such returns. Other individuals may wish to reside in senior housing, assisted living, or independent apartment living. The identification of affordable and appropriate housing will be addressed by FSSA and the Community Choice Commission.
B. Methods of Effectively Addressing the Problem:
Description of Methods: Indiana intends to use the first year of the grant period to plan the transition and diversion projects, establish collaborative partnerships, secure consultation resources, and initiate specific planning for systems change processes.
Grant monies will be used to fund consultant services to: ensure coordinated and consistent efforts of local partners; analyze optimum strategies for the use of fiscal intermediaries; oversee the preparation of educational materials for providers and consumers; establish specific outcome and impact measures; facilitate coordination of data collection and analysis; facilitate reports and public presentations, and enhance information and communication among all partners.
Participation in the grant transition and diversion projects is open to Medicaid eligible persons (or persons eligible within six months) residing in an Indiana nursing facility, or to any Medicaid-eligible Indiana resident in-patient soon to be discharged from an Indiana hospital. Based on a data report of Minimum Data Set (MDS) data (1999), of the 42,296 total residents in Indiana Medicaid-enrolled nursing facilities, an estimated 5,529 residents of all payer type would likely make the strongest candidates for community care because they have relatively low needs.
The grant transition and diversion projects are open to persons of any Resource Utilization Groups (RUGs) category and participation is strictly voluntary. Consulting services will help identify methods of determining grant participants. Additionally, Indiana will have access to PAS and PASRR screening processes and RUGs data to identify potential individuals and their specific care needs. In addition, other variables will be considered for each individual such as the emotional, and psychosocial strength of the person, the quality of the person's present environment, and the quality of life available to the transitioning individual in the new living environment. The process for identifying candidates is described further in the Workplan, Step 5.1.
Each candidate for transition will have access to a case manager, independent living services, and an ombudsman who will cooperate in providing information, assuring residents rights, advocating for the individuals and their decisions, and developing a person-centered plan. Included in this plan will be a list of all services to be provided, the costs of these services, and the identity of the providers.
Eligible for the diversion project will be 20 Medicaid eligible hospital in-patients who will soon be discharged. PAS and PASRR screening processes will be used to identify these persons along with the same variables that will be considered for persons to be transitioned such as the emotional and psychosocial well-being of these persons.
In addition, information available from case managers and PAS and PASRR screeners indicates that returning to the community involves much more than securing home care services, especially for residents of nursing facilities who may no longer have their own homes. This project will identify or develop protocols for the activities and services needed to bring about a successful transition or diversion experience and ensure the physical, psychological and social well-being of these persons in their new living environments. These actions may include but are not limited to: establishing partnerships with hospital discharge planners; locating appropriate housing; providing rent/security deposits for the first month; securing appropriate furnishings and clothing; providing psychosocial supports; establishing partnerships with available senior housing and Section 8 housing; and providing crisis intervention services, special equipment and personal assistance services.
For those individuals unable to return to their own homes, a critical need is suitable housing. During the past year the DDARS Bureau of Aging and In-Home Services has been collaborating on the use of HUD housing vouchers with the FSSA Division of Family and Children (State Housing Authority). This resulted in the submission of a HUD grant proposal for 51 housing vouchers for older adults and persons with disabilities. These vouchers will potentially enable persons participating in the transition/diversion grant projects to access suitable, affordable housing.
Other services that will be made available to persons in the transition and diversion projects include: home health services and supplies; home delivered meals; homemaker; employment supports; transportation; adult day services; home modifications; personal emergency response systems; adaptive aids and devices; and other services to be identified by the consumer. It is also anticipated that approximately twenty grant participants will be provided with consumer-directed personal assistance services through the Community PASS grant proposal submitted by the State. If both projects are funded through these proposals the Nursing Home Transition project would include 4 areas of Indiana that would constitute the following:
| Nursing Home Transition 20 consumers |
Nursing Home Transition and Community PASS 20 consumers |
| Nursing Home Diversion 20 consumers |
Community PASS (at least three additional areas) |
Residents participating in the transition and diversion projects will be involved in all aspects of the decision-making process which includes person-centered planning; development of an individualized care plan; identification of emergency contacts; quality assurance procedures; grievance and appeals procedures; and the availability of written educational materials which address the transition/diversion process.
Ombudsmen will assist in the transition/diversion processes by educating nursing facility residents, their families and the general public about the grant projects, the rights of nursing facility residents, and about their ability to make choices and determine their living situations. ILCs will be enlisted to provide self-advocacy, peer support, training and material development. Ombudsman and ILCs will also assist in the education of nursing facility residents about their rights and options; education of the public about the ability of individuals to be served in the community and the right of persons to choose their living arrangements; and education of both residents and the public on the meaning of advocacy. These efforts will stress consumer control, choice, and self-direction. This effort will further contribute to advocacy education in the state.
2. Reasonableness of Methods and Expression of Confidence: Indiana has established successful in-home services and community-based programs which provide a variety of services aimed at preventing premature or inappropriate institutionalization. The key aspects of the IN-Home Services Program include: one case management system to access all funding streams; one eligibility screen for in-home services and nursing home placement; and one data reporting system (INsite). This process insures that services are integrated and coordinated by service delivery planning that considers the entire spectrum of needs, from complete independence through increasing degrees of dependency. Current policy dictates that case managers meet with consumers at least every 90 days to review services, quality of life issues, on-going supports, and health and safety issues.
These programs are already in place to ensure that transitioning persons will have the same services and levels of care in their new living situations, which are the communities and residential options of their choice. These services may be amended or enhanced as needed to include persons in the transition and diversion projects. Also, the INsite system will include data on transitioned and diverted individuals, participating nursing facilities, and housing costs.
C. Coordination and Linkages:
- Complementary Initiatives: Realizing that a successful transition project involves many parameters, the state, through FSSA plans to utilize several entities in Indiana including the AAAs, the State Long-Term Care Ombudsman, ILCs, Adult Protective Services, Arc of Indiana, the Indiana Association of Rehabilitative Facilities, the Governor’s Planning Council for People with Disabilities, nursing facility associations and facilities, home health associations and providers, and assisted living associations and facilities.
- Coordination with Other Funding Sources: Indiana's Statewide IN-Home Services Program brings together funding from the CHOICE program, Title III of the Older Americans Act, the Social Services Block Grant, the Older Hoosiers Account, six HCBS waivers, the U.S. Department of Agriculture Meals program, and local and private funds. In addition, FSSA coordinates additional community-based services such as congregate meals, information and referral, legal services, ombudsman, preventive health services, adult protective services, adult guardianship, money management and representative payee programs. The Office of Medicaid Policy and Planning (OMPP) will be an integral part of the project. Kathleen Gifford, Assistant Secretary (see letter of support), and staff will be directly involved in all planning efforts regarding the use of Medicaid funds. Ms. Gifford’s direction will be crucial to the amendments of Medicaid waivers to facilitate the transition of consumers and to on-going system change.
- Commitment from Partners: In addition to the associations and state government agencies mentioned above, FSSA will have the cooperation of the Indiana State Department of Health; the FSSA Division of Mental Health and Addiction Services; and the DDARS Bureau of Developmental Disabilities Services (BDDS), which will assist in the identification and determination of persons eligible for the transition or diversion projects. The grant will be under the direction of the Community Choice Commission, which will be appointed by Governor O'Bannon, with FSSA serving as the lead agency. The Commission will also partner with the following entities: CHOICE Board; Governor's Planning Council for People with Disabilities; Indiana Assisted Living Association; Indiana Association of Area Agencies on Aging; Indiana Association for Home and Hospice Care; Indiana Association of Homes and Services for the Aging; Arc of Indiana; Indiana Association of Rehabilitative Facilities; Indiana Council on Independent Living; and the Indiana Health Care Association. The roles of these organizations are described further in the Partnerships section of this proposal.
The grant intends to expand outreach efforts by enlisting the help of the local coalitions including ILCs. These grant partners will present information to residents, resident councils, families and other caretakers. Educational efforts will include distributing literature and hosting seminars about the services available; providing information on consumer directed care, funding options through this grant, the State's commitment for future funds, and about safeguards such as personal emergency response systems, respite services, and 24-hour contact numbers. The State Long-Term Care Ombudsman will especially assist in preparing materials that describe the grant projects and the selection process.
The grant proposes a similar outreach program for hospital in-patients of all ages and conditions who are at greatest risk for nursing home placement. These individuals and their families or other caregivers will be contacted and provided with information about the diversion project. Information describing the project and the selection criteria will be drafted in partnership with the State Long-Term Care Ombudsman and Independent Living Centers.
In collaboration with the local ombudsmen, case managers assigned to the transition project will conduct the in-person visit with the resident who has expressed a desire to transition to another setting. Residents who choose to participate will be advised of the services available for the transition and assured of on-going funding (applying for the IN-Home Services Program) and community support. The State and other local partners will inform and work with the nursing facility regarding all impending transitions.
FSSA will specify local coordination and cooperation as the condition of participation in this grant project. Proposals will be solicited for local participation in these projects. This process will also state that on-going support for the grant projects will be required of participants. Only coalitions of local AAAs, nursing homes, ILCs, ombudsmen, home care providers, local offices of the Bureau of Developmental Disabilities Services, Community Mental Health Centers, and assisted living facilities who agree to cooperate and ensure the effective transition of residents and on-going support will be selected to participate in this effort.
Also, FSSA is partnering with the Independent Living Centers in the State on the Nursing Facility transition project. Submitted with this grant is a complementary proposal from the Independent Living Centers detailing their goals and objectives and methods of achieving those goals.
FSSA has submitted an application for HUD housing vouchers. Transitioning individuals will have access to the community and in-home services listed above, and to assistance with housing which may involve the use of HUD vouchers (pending approval of this process).
OMPP, which is part of FSSA, will play a central role in working with the local partners and providing direction for the initiative. OMPP can capitalize on its on-going working relationships with Indiana’s nursing home associations and groundwork for the Nursing Home Transition process that was laid at that time. FSSA has already begun discussions will the state's two nursing home associations regarding the goals and objectives of transition project. Also, the proposal submitted with this grant from the Independent Living Centers in Indiana demonstrate the commitment of both the State and advocacy groups to work together to achieve true systems change.
D. Work Plan
The Community Choice Commission, through the work of FSSA, intends to address infrastructure development and system issues to comply with the intent and conditions of this grant announcement. The following objectives and action steps will implement the grant objectives of planning for systems change, and implementing transition and diversion direct services projects, through these activities: planning and grant administration, formation of partnerships and coalitions, education and outreach, implementation of transition and diversion projects, data retrieval and report preparation, and evaluation.
Objective 1. To develop models for the transition and diversion of eligible persons.
Action Step 1.1 Formation of an advisory council. FSSA will establish a project advisory council through the Community Choice Commission. Membership of the Commission will include consumers of community-based and institutional services, advocacy groups, providers, state agencies such as FSSA, the State Department of Health, the Department of Transportation, and ILCs. The Commission council will be established by September 2001. The initial meeting will occur by October 2001.
Action Step 1.2 Development of a request for proposal for consulting services. This competitive process will be used to solicit a vendor or vendors for consultant services for coordination, research, planning systems change, providing reports, change analysis, and to coordinate and manage the grant implementation. The process will be finalized by December 1, 2001. Selection of an individual or a consulting firm will be made within 60 days.
Action Step 1.3 Project planning. Indiana plans to devote the first year of the grant period to developing an infrastructure to be used for effective transition and diversion processes. The consultant and project staffs will work closely with the Commission to achieve this goal. The planning activities of the consultant will begin upon execution of its contract and continue for twelve months, with plan revisions made throughout the life of the grant.
Action Step 1.4 Development of a request for proposal for local coalition participants. This will be used to obtain coalitions of participants in the project requiring: AAAs; nursing facilities; assisted living facilities; ILCs; Arc of Indiana; local offices of the BDDS; hospitals; home care agencies; ombudsmen and all other vendors. At least three local coalitions will be funded. It is anticipated that at least two nursing facilities will be involved in each coalition. All coalition members must agree to participate and achieve the goals of the grant project. Proposal development will be finalized by December 1, 2001. Selections will be made within 60 days.
Action Step 1.5 Execution of contracts. The execution or amendment of contracts will occur within 60 days of the selection of consulting services and local coalitions through the process in #1.2, and #1.4 above.
Objective 2. To provide education and outreach services about the nursing home transition portion of the project to nursing home residents, facilities and social service professionals involved in the grant projects.
Action Step 2.1 To develop outreach materials, using the coalitions of participants in #1.4, and working with the ILCs. Materials to be evaluated by the Commission and consultants. To be prepared by July 1, 2002.
Action Step 2.2 To disseminate information to patients in nursing home facilities about transition opportunities. Information will be provided initially by August 31, 2002. On-going dissemination will also occur as a component of system change.
Action Step 2.3 To provide nursing home facilities with information on Indiana's transition project. Information, including a description of the selection process and project goals and timelines, will be provided by August 31, 2002.
Action Step 2.4 To contact potential providers of in-home services for transitioning persons and supply the providers with information. Contact to be made by August 31, 2002.
Action Step 2.5 Specialized training related to the nursing home transition portion of the project. Each partner participating in this project will participate in training. One primary and one secondary case manager will be identified for this project. These case managers will be identified within 30 days of the contract award to coalitions. Curriculum development will begin within 30 days of the grant award. Training will be conducted under the current contract with the Indiana Association of Area Agencies on Aging and the ILCs and will be conducted by September 30, 2002.
Action Step 2.6 To involve State and local ombudsmen in training, information development, and dissemination of information to nursing home residents. Activities will be completed by September 30, 2002.
Objective 3. To provide education and outreach services about the diversion portion of the project to hospital in-patients and their families; to train case managers and hospital discharge planners.
Action Step 3.1 To develop outreach materials using the efforts of coalitions and entities mentioned in #2.1. Materials to be evaluated by the Commission by July 1, 2002.
Action Step 3.2 To provide hospital in-patients and their families with information on Indiana's diversion project. Information will be provided by August 31, 2002 and on-going.
Action Step 3.3 To provide hospitals, discharge planners, and other social service professionals with information on the diversion project. Information, including a description of the selection criteria and project activities and timelines, will be provided by August 31, 2002 and on-going.
Action Step 3.4 To contact providers of in-home services regarding the potential for providing services to persons participating in the diversion project. Contact to be made by August 31, 2002 and on-going.
Action Step 3.5 Specialized training for the diversion portion of the project. Case managers will be trained following the guidelines listed in #2.5. Training to be conducted by October 15, 2002.
Action Step 3.6 To provide education and training for hospital discharge planners and others participating in the diversion project. Education and training will take place by October 15, 2002.
Action Step 3.7 To involve State and local Ombudsmen in training, information development, and dissemination of information to hospital in-patients. Activities will be completed by October 15, 2002 and on-going.
Objective 4. To collaborate with nursing facilities, nursing home associations, housing partners, and assisted living facilities.
Action Step 4.1 Coordination with nursing facilities, assisted living facilities, and respective associations. Dialogue with these associations will be instituted by November 1, 2001. They will be notified that Indiana has been selected within 7 days of the grant award.
Action Step 4.2 Coordination with the State Housing Authority, which is part of FSSA. A request for 51 housing vouchers has been submitted to HUD. In March 2001, the Bureau of Aging and In-Home Services (BAIHS) and the State Housing Authority began discussion concerning the use of HUD housing vouchers for this grant. Coordination with the State Housing Authority to use these vouchers and to identify other housing opportunities available through HUD financed projects will be initiated by November 30, 2001.
Objective 5. Identification and selection of candidates to be transitioned. This objective will also apply to the third year of the grant.
Action Step 5.1 Identification of candidates for the transitioning project. The consulting service contracted to oversee the planning for system change will provide expertise in methods of identifying candidates. This will be presented to FSSA and the Commission. This process will be finalized by June 30, 2002 and implemented by October 1, 2002.
Action Step 5.2 Selection of residents and facilities. As residents are identified (see 5.1 above), they will be notified in person and in writing. Contacts will begin by October 31, 2002. This process will meet the requirements of Title VI of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; Hill-Burton Community Service nondiscrimination provisions; and the Americans with Disabilities Act.
Action Step 5.3 Development of individualized care plans. The development of a person centered plan, and an individualized support plan will be developed. This will begin with an initial contact between the case manager and resident (see 5.2 above). At least 50% of all planning will be completed within 45 days of this contact. The remaining planning will be completed within 90 days of this contact with any modifications made as necessary.
Action Step 5.4 Initiation of transition services. The transition process will begin by October 1, 2002. This will include arrangement of housing alternatives, modifying home structures, consulting with relatives and families, securing necessary in-home and community-based services. Twenty nursing home residents will be transitioned during each of the second and third years of the grant.
Objective 6. Identification and selection of candidates to be diverted. This objective will also apply to the third year of the grant.
Action Step 6.1 Selection of participating hospitals. Hospitals will be solicited to participate in the diversion project. Agreements with hospitals to be obtained by March 30, 2002.
Action Step 6.2 Analysis of hospital in-patient functional characteristics, current discharge patterns, and referral sources for diversion candidates. Identification of potential in-patients characteristics to be used to be obtained by July 31, 2002.
Action Step 6.3 Identification of eligible hospital in-patients. Potential candidates will be identified by referral from physicians, primary care nurses and discharge planners, Persons so identified will be assessed using PAS and PASRR tools, and evaluated for participation. They and their families or caregivers will be notified in person and in writing as soon as they are identified, and will be provided with information needed to understand their options. Initial contacts will begin by August 31, 2002. This process will meet the same requirements as #5.2 with regard to the Civil Rights, Rehabilitation, Age Discrimination and Americans with Disabilities Acts, and the Hill-Burton Community Service nondiscrimination provisions.
Action Step 6.4 Development of individualized care plans. Individualized, person-centered plans will be developed, starting with the initial contact between the case manager and the in-patient (see # 5.3). These plans will be completed within 3 days of this contact.
Action Step 6.5 Initiation of services to diverted persons. Services will begin at discharge from the hospital; to include arrangement of housing alternatives, modifying home structures, consulting with relatives and friends, securing necessary in-home and community-based services. At least ten persons will be diverted during each of the second and third years of the grant.
Objective 7. Evaluation and Report Preparation
Action Step 7.1 Modification of data collection tool. DDARS, AAAs and BDDS will use a single data collection tool (INsite) for the In-Home Services Program. This tool collects demographic data, costs, funding sources, quality assurance measures, and other information. The grant project proposes to use the same tool (INsite) to track the cost of entering a nursing facility for persons who have to be temporarily placed before being returned to their communities, the cost involved in transitioning nursing facility residents to other living arrangements in the community, and the cost of community living arrangements for transitioned and diverted persons. Modifications to INsite will be needed to accumulate this data, and to also specifically identify these residents or include any elements to be determined necessary to the transition/diversion processes. All modifications will be finalized by July 1, 2002.
Action Step 7.2 Development of process reports. The Bureau of Quality Improvement Services will be crucial to the development of these reports. Process evaluations will be conducted periodically, to include interviews with participants and case managers. Results from these evaluations will be available to refine the transition and diversion projects as the grant progresses. Process reports to be completed at quarterly intervals.
Action Step 7.3 Development of outcome-based reports. Indiana will comply and meet all reporting timeframes specified for the grant process. Using data collected by INsite, the state will report on the grant, waiver, and public assistance funds used to implement the project. Working with the Commission and project consultants, outcome-based reports will be developed using additional data collection methods identified during the development process, that identify the impact of the grant. These include but are not limited to: quality of care; quality of life; impact of assisted living; costs; need and utilization of services; transition time frames per resident by functional classification; impact to the involved nursing facilities; and identification of resident positive and potentially negative characteristics responding to specific interventions and settings. Reports shall be submitted at quarterly, annual, and project end intervals.
E. Organization, Management and Qualifications
- Circumstances Effecting the Ability to Recruit and Hire Staff: Indiana will use a request for proposal (RFP) process to solicit applicants for contract employment. Contracts are then prepared for selected candidates and forwarded to the established state process to complete a fully executed contract.
- Qualifications of Key Project Staff, Stakeholders and Partners: This project will be administered by the Indiana Family and Social Services Administration, under the direction of Governor O'Bannon and the Community Choice Commission. The Division of Disability, Aging, and Rehabilitative Services (DDARS) will assist with the solicitation and review of RFPs, coordination of the Ombudsman program and Independent Living Centers, activities related to INsite software and reporting, and coordination of case manager training. DDARS will have contractual relationships with: consultant(s) to oversee, evaluate and coordinate the project; and with the minimum of three coalitions selected to participate in the grant projects. The Office of Medicaid Policy and Planning (OMPP), also part of FSSA, is the Medicaid Single State Agency and will be a major partner in this grant effort.
- Direct Professional Experience with Disabilities or Long Term Illnesses: Prior to his current position as Assistant Director of BAIHS, Mr. Robert Hornyak was employed as a vocational rehabilitation counselor, counselor supervisor and program director. He has also worked with youthful offenders, persons with developmental disabilities and individuals with mental illness, utilizing his Masters degree in Clinical Psychology. He is a Licensed Clinical Social Worker.
- Significant Roles of Persons with Disabilities or Long Term Illness: Persons with disabilities will be integral members of the Community Choice Commission. These persons are also represented on the Indiana CHOICE Board, and the Indiana Governor's Planning Council for People with Disabilities. In addition, continued and regular dialogue will be established with ILCs and other consumer directed organizations. The ILCs will have major roles in the development of education materials, and training of consumers.
Ms. Alison Becker, Director of DDARS’s Bureau of Fiscal Services, is coordinating Indiana's application for all aspects of the systems change grants to CMS and implementation of the plan. She also will be the liaison with the Community Choice Commission. Ms. Angela Spittal, Deputy Secretary of FSSA, will coordinate efforts between FSSA and the Governor’s Office. Ms. Jackie Pitman, Director of the DDARS Bureau of Strategic Support Services, will provide coordination and advising on all training and consultation activities. Ms. Chris Newman, Director of the Bureau of Quality Improvement Services, will provide coordination of all quality assurance and quality improvement activities.
Mr. Robert Hornyak, Assistant Director of the BAIHS, has allocated 5% of his time to the performance of his project duties. Ms. Dortha Joyce, Assistant Director of Field Services for DDARS's Bureau of Developmental Disability Services (BDDS), will allocate 5% of her time to coordinating the efforts of the local BDDS offices and the State BDDS office on this project.
Ms. Carol Warner, Unit Manager for Program Planning and Program Assistance Functions, has 10% of her time allocated as Project Manager for this grant. She will supervise, direct, and support the activities of the Grant Coordinator, consult with the person or agency contracted to consult for the grant, and provide technical advice in the development of materials and reports. Ms. Patty Matkovic is the Grant Coordinator with 25% of her time allocated to the following grant projects: reviews of the participating facilities, technical assistance to local coalitions, educational efforts, research for materials development and report compilation.
A copy of the resumes for Ms. Becker, Ms. Pitman, Ms. Newman, Mr. Hornyak, Ms. Joyce, Ms. Warner and Ms. Matkovic are located in Appendix C of this application.
Ms. Carol Warner serves as a management team leader in the development and implementation of program policies and procedures and has experience working with nursing facilities and community groups. She is has extensive experience with Medicaid level of care issues regarding individuals with developmental disabilities.
Ms. Patty Matkovic brings to her position of grant writer a strong background in research and reference. Until January 2001, she managed a medical library and gained experience in management, information retrieval and use of the Internet.
3. Significance
A. Enduring Change:
The State has clearly expressed its commitment to creating enduring system changes in integrating persons with disabilities into community-based living. The June 1, 2001 report to Governor O'Bannon by the Family and Social Services Administration entitled Indiana's Comprehensive Plan for Community Integration and Support of Persons with Disabilities (Community Integration Plan) outlined the following six major policy directions that will advance the development of community-based services:
- Emphasize consumer choice: enable individuals to receive the types of services they desire in the location they prefer.
- Provide information, assistance and access to consumers to increase their opportunity for informed choice.
- Support the informal network of families, friends, neighbors and communities.
- Strengthen quality assurance, monitoring systems, complaint systems and advocacy efforts.
- Increase the system capacity for provision of high quality care.
- Create a coordinated workforce development system that recruits and supports a stable resource of direct support staff.
The Community Choice Commission overseeing this grant process and implementation of the Community Integration Plan will include these policy directions as their system change goals. These directions will: allow individuals from a variety of viewpoints to discuss the strengths and weaknesses of the current system; permit recommending and monitoring changes to the system; provide for on-going dialog regarding the success of the grant demonstration projects; and schedule regular meetings to report on the progress the state has made, and to listen to the concerns of Indiana's citizens. The Commission will communicate with the public on progress through newsletters, regular written reports and frequent public hearings throughout the state. Also, the coordination of this proposal with the complementary proposal from the Independent Living Centers will take place through the Commission.
The areas designated for change or improvement by these grant funds are: assuring appropriate use of nursing home services versus community services for individuals currently living in nursing homes; access to available housing arrangements, including assisted living facilities; consumer directed attendant care; and funded targeted case management services.
The third area with the potential to be improved through grant funds is access to available housing arrangements for persons who have transitioned from nursing homes or diverted from nursing home placement. The Community Integration Plan recommends recognizing the role of affordable housing as the single biggest need for individuals who are at risk of institutionalization and strengthening linkages between "service" agencies and organizations responsible for housing. By utilizing the Community Action Programs, available HUD housing vouchers, and local housing assistance programs, these individuals should have safe, affordable housing available to them. A number of AAAs have utilized innovative financing strategies to construct low-income housing. This availability will be reviewed as local coalitions submit proposals for participation in this process. Additionally, best practices will be shared with other areas of the state.
Another housing option available to transitioning persons is assisted living. Considerable discussion and consultation has occurred over the past five years to determine the feasibility and methods of developing an assisted living model using public funds. Because Indiana has received approval for an Assisted Living Waiver, grant participants will have the option of applying for and utilizing assisted living services. Choosing assisted living facilities for the grant transition and diversion projects will greatly aid Indiana in developing a transition model for future use. The grant will also provide the opportunity to work with assisted living providers, and enable the consultant to retrieve important data regarding consumer outcomes and satisfaction with housing and services. To insure that individuals will not have to move to other housing arrangements at the end of the grant period, there will be firm agreements for continuation of housing at these residences, and existing funding will be utilized to the greatest possible extent.
Only assisted living facilities that have disclosed information under Indiana's disclosure law (IC 12-10-15) will be approached to participate in this effort. Facilities willing to participate must agree to reimbursement under the Medicaid Waiver rates. These facilities must also accept the following stipulations: resident admission and move-out criteria; continuation of housing arrangements and acceptance of the same reimbursement rates after the grant ends; criteria for reports and data tracking; dissemination of information to consumers through appropriate use of the media; quality assurance procedures; and other criteria to be mutually established and agreed upon.
The second area designated for systems change is a consumer-directed attendant care program. Under new provisions of Senate Enrolled Act 215, consumers have a much greater ability to self-direct attendant care services. Allowable activities include homemaker services, transfer and mobility assistance, medication management, meal planning and preparation, dressing and grooming, and other assistance that the person could do for themselves if they did not have a disability. The state is also applying for a Community-Integrated Personal Assistance Services and Support Grant to expand and further develop its attendant care program. Because the funding is geared toward infrastructure changes, this will aid consumers and effect a systems change through projects that can endure beyond the end of the grant period.
A third area of focus is enhancement of the case management system. Case managers are challenged to find a funding source to work with nursing facility residents who want to return to their homes, to develop housing and service plans for them, or to monitor their progress in their returns to the community settings of their choice while they are still residents of the nursing facility. Case manager services funded through this grant will be a demonstration of the effectiveness of the provision of targeted case management through the Medicaid State Plan. The development of targeted case management for this population will help assure enduring change in the manner in which long-term care services are planned for and delivered. Indiana has submitted a State Plan amendment to add targeted case management services for persons with developmental disabilities. This will greatly expand the availability of this service. The Commission will use the best practices of this new service provision to create expanded service availability for older adults and persons with disabilities.
B. Assistance with Key Goals and Objectives:
This grant will provide Indiana with important data, case management experience, consumer information, linkages with local Independent Living Centers and administrative experience to assist the state in creating enduring systems of change. The grant projects concentrate on giving persons access to the living arrangements of their choice, and to accessing the available in-home and community based services. They also focus on improving the quality of services used by clients through programs such as consumer directed attendant care.
C. Sustainability:
The Community Integration Plan gives directives that will ensure that changes in the system endure after the grant period. For example, the directive to increase the support of local communities guarantees that local collaboration in these grant efforts will be strengthened by state support. The system will be further built on the education, outreach, and partnerships discussed within this proposal. Local communities, providers, consumers, advocacy organizations and state agencies will enhance communication and knowledge bases to provide more comprehensive and consumer-focused services.
One of the most critical factors in selecting the participating sites will be that funding for services will continue to individuals who have transitioned from nursing homes after grant funds have been exhausted. Local agencies can access many contracted public funding sources beyond the Medicaid HCBS Waivers and the use of some of these funds could be appropriate for services for the transitioned population. For example, $4 million of the total IN-Home Services Budget consisted of local funds at the Area Agency on Aging level. Several entities have inquired into the use of these and other funds as match for Medicaid HCBS Waivers. If successful in this grant solicitation, Indiana will pursue the mechanism to obtain Federal Financial Participation (FFP) for these local dollars and seek out other partners. One avenue to ensure that the grant projects continue is to capitalize on this aspect through the Assisted Living Medicaid Waiver. This will be a creative mechanism to increase local commitment to statewide initiatives and expand the impact of these local funds.
As these initiatives unfold, the Commission will collaborate with state agencies and local partners to incorporate best practices into training/information sessions to be shared throughout the state. Training techniques and methods will be employed to disseminate this information to adult learners. The Community Choice Commission and consultants will implement training on necessary changes to the planned approaches.
4. Partnerships
A. Consumer Partners
The primary advisory council for this grant will be the Community Choice Commission. This group will bring together consumers of community-based and institutional services; legislators; advocacy groups; and State agencies. This Commission will provide on-going leadership for community integration, public discussion, and a mechanism for consistent quality assurance. Also, the Commission will communicate to the public on progress through newsletters, regular written progress reports and public hearings. Additional public discussion and input will occur through boards such as the CHOICE Board, Arc of Indiana, Community Residential Facilities Council, Commission on Aging, and the Indiana Governor's Planning Council for People with Disabilities.
The CHOICE Board consists of people who represent senior citizens, individuals with disabilities, persons with mental illnesses, providers, home care services advocates, gerontology specialists, and others. The Commission on Aging advises the state on matters effecting the elderly. The Indiana Governor's Planning Council for People with Disabilities provides advocacy and project funding for persons with disabilities. The Community Residential Facilities Council represents services for persons with developmental disabilities in setting such as group homes. Independent Living Centers will provide direct linkage to services and advocacy on behalf of consumers.
Local partnerships are the key mechanism to assure success in this endeavor and for future change. The solicitation of local projects will help assure the commitment of the these partners. Only proposals clearly demonstrating a high level of partnership and commitment will be awarded funds through this grant.
The enclosed grant proposal from the ILCs demonstrates evidence of another important partnership. Both projects will be more effective as a team effort.
B. Public/Private Partnerships
This project will require the establishment of a number of partnerships necessary to ensure the smooth transition of nursing home residents into the community. The close collaboration of FSSA with other state agencies, e.g., Indiana State Department of Health, Department of Workforce Development, and the Indiana Housing Finance Authority will be critical to the integration of individuals into the community. Safe affordable housing, regulatory oversight and a high quality, trained workforce are needed and necessary factors in achieving success.
In addition, the Commission will partner with the following public associations: Indiana Area Agencies on Aging, Indiana Assisted Living Federation of America, Indiana Association for Home and Hospice Care, Indiana Association of Homes and Services for the Aging, Indiana Council on Independent Living, Arc of Indiana, Indiana Association of Rehabilitative Facilities, the Governor’s Planning Council for People with Disabilities, Indiana Health Care Association, Indiana Home Care Task Force (a coalition of over 30 advocacy groups); United Senior Action; and primary consumers and their families.
Initial discussions with many of these groups have revealed enthusiastic support for this grant submission. The enclosed letters of support from these organizations describe how they will help in implementing the grant objectives, and assist in making system changes.
5. Formative Learning
A. Mechanism for Tracking Program Goals, Objectives and Outcomes:
The monitoring plan is one of the most critical elements of the transition process. The Community Choice Commission will be the primary means of gaining consistent consumer and advocate input, as well as brining agencies throughout State government together to discuss issues and find solutions to the problems that inhibit community integration. Consultants funded through this grant will work with FSSA but will clearly receive direction from the Commission and will provide tracking of goals, objectives and outcomes to the Commission. The consultant(s) will also participate in onsite visits to assure that the project is proceeding according to the stated expectations and time-lines. Reports from these visits will become part of the quarterly process evaluations to be completed by the consultant(s).
Case managers will gather individual level data. They will be in frequent contact with consumers throughout the transition process to insure that individuals are adjusting well to their new living conditions, are receiving all the necessary services, and are informed enough to understand the service array available, and comfortable enough to alert others of problems.
B. Means of Incorporating Feedback into the Project's On-going Operations:
The first year of the grant project will include work to determine the optimal means of gathering, analyzing, and synthesizing feedback on operations. This will be incorporated into the direct service components. This feedback will be an on-going process to the Community Choice Commission and FSSA.
One example of information to be used is the Quality Improvement Process (QIP) developed through a demonstration quality assurance grant from the Robert Wood Johnson Foundation. Indiana’s 16 Area Agencies on Aging use this process. Consumer confidentiality is first protected, and then consumers are questioned on a number of areas. Scores are aggregated and provided to vendors to improve the quality of services. The QIP program can be amended to include individuals participating in the grant's transition and diversion projects. Part of the development process for this grant will consist of determining the statistics to be collected, such as qualitative and quantitative data, and the form in which it will be gathered, such as through satisfaction surveys and interviews. FSSA, project consultants, and Commission members will analyze this information.
The Bureau of Quality Improvement Services (BQIS) has developed provider standards, monitoring mechanisms and staff, and processes of inclusion for persons with developmental disabilities. Transition, diversion, and community inclusion are focal points for BQIS. Persons involved in this grant who have a developmental disability will be monitored by the 19 field monitors under BQIS. This in-depth monitoring and tracking will also be used in best practice studies for the entire population receiving services and for system change activities.
6. Budget and Resources
Please see budget submission for all details on this proposal.
For this project, FSSA is submitting a total budget of $1,652,389 ($1,147,500 federal and $504,889 state). State funds will be from Indiana’s CHOICE program. This is a 100% state funded account. This amount exceeds the required 5 percent in-kind or third-part contribution.
The program narrative details the activities to be carried out through this proposal. Grant funds will not be used to supplant or replace existing State or federal funds.
Grant Budget Justification (Federal)
TRAVEL $8,700
Out-of-state conference attendance and in-state monitoring.
SOFTWARE $25,000
Modifications to current database(s) to track project demographics, costs, time, outcome measures.
TRAINING $20,000
Training will be conducted for consumers, case managers, nursing facility staff, assisted living staff, Independent Living Centers, Ombudsman and others involved in this process. This will focus on person-centered planning, consumer direction, fiscal intermediaries, and resident’s rights.
RUGS $10,000
The most recent specific identification of nursing facility residents was conducted in 1999. Updated information and grant specific data requests will be formatted.
CONSULTANTS $375,000
Consultants will be solicited to provide expertise in project design, material development, monitoring, training, evaluation design and reporting. Staff from successful other state projects (maximum of two) will be invited to Indiana to learn from their experience. Based on a cost of $125/hour, this includes: 25 hours per week in year one; 20 hours per week in year two; and 15 hours per week in year three.
LOCAL ADMINISTRATION $78,000
Costs for local coalition administration. Specifically based on proposals received by FSSA, this may include: supervision, staff education, outreach, information and assistance, monitoring, and other allowable costs.
CASE MANAGEMENT $66,800
Cost of case management services ($38.39/hour) not billable through current processes. This includes planning and coordinating activities while residents are in nursing facilities, services to persons not yet Medicaid eligible, and services to persons on waiting lists.
HOME-BASED SERVICES $564,000
To demonstrate the systems designed and changed through the planning process, at least 40 persons will be transitioned from nursing facilities into home or community based care, and at least another 20 persons will be diverted from nursing facility placement. These costs include (when applicable): costs in assisted living facilities (average $1,900/month); first month rent/security deposit; furniture, clothing; attendant care and other services; personal emergency response; home modifications; adaptive aides; crisis intervention; peer support; and other necessary services.
