Enhanced Nursing Home Transition

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Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

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Goals

• Provide a context for discussing change in
  Pennsylvanias Long Term Living system
• Provide key information for staff to support
  Enhanced Nursing Home Transition

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Improving Access to LTC Options

• States are looking at best methods to avoid
  unwanted institutionalization
• Managed Care (Arizona, Texas, New York)
• Various Nursing Home Transition programs
• Nursing Home Transition programs
• Large statewide programs (WA, NJ, Oregon)
• State employees (NJ, WA)
• Contracted organizations (CO)
• Small programs for most challenging (SC, CT)
• Locally based organizations (Centers for
  Independent Living, Area Agencies on Aging)

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The Pennsylvania Picture

• Three Imperatives to Balance the Long Term Living
  System in PA
• Demographic trends
• Consumer choice
• Fiscal challenge

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Pennsylvanias ProgressShare of NCBS Waiver
users has increased since 2002-03
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Enhanced Nursing Home Transition

• Strengthened collaborations
• Active engagement of AAAs and DPW NHT partners
• Incentives for agencies to achieve successful
  transitions
• Special funding for Transition Services
• Unified Data Tracking
• MDS Data
• LTL Counseling

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Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

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Minimum Data Set (MDS) Reports
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(No Transcript)
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Run Date 08/01/2006County Lancaster
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Lancaster MDS Information

• Number of people identified 163
• Number of Nursing Facilities listed 28
• Number of short term 44
• Number of long term 44
• Number of uncertain discharge 75
• Number of people with a dementia-type diagnosis
  50
• Number of people Over 60 157
• Number of people Under 60 6
• Number of people in each facility
• Audubon Villa 3
• Short Term 0
• Long Term 0
• Uncertain - 3

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Unified Data Tracking

• Module has been created in OMNIA to collect
  transition data
• All agencies will use the same system
• Real time data collection to allow ready access
  to critical information

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Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

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Comparison of working with a newly admitted
resident vs. long term resident
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Myth Most People in Nursing Homes Need to be
There

• Those who resist change say People in
  nursing homes today are too frail to live in the
  community. Only a few of them can really leave.
• Fact For every person in a nursing home who
  needs assistance with 3 or more activities of
  daily living, there are 1.83 people living in the
  community who have the same level of disability.
  

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Generalizations regarding newly admitted residents

• Overwhelmed by process that lead to NHP
• Informal support present and engaged
• Come from acute care or home setting
• Usually still have residence, material
  possessions
• Apprehensive

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Generalizations regarding long term residents

• Informal supports have relaxed or gone away
• Loss of material possessions
• Resignation to institutionalization
• Dependent upon NH staff, schedule, supports
• May be in grief/loss cycle

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Change Loss Grief

• Important factor is not that the change is good
  or bad, but that it is perceived as a negative
  event

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Kubler Ross (1969)

• Grief/Loss cycle
• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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Roller coaster ride of the grief/loss cycle
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Barriers to NHT

• Irrational fears/thoughts
• External influences/institutional bias
• Lack of supports
• Housing issues
• Lack of knowledge regarding availability of
  community services
• Ageism

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How to Address Barriers

• Differentiate between rational and irrational
• Express that consumer/informal supports have
  control/support
• Change the dialogue
• Challenge fears
• Develop support systems
• Be available
• Be supportive, not smothering
• Tout the success stories

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Windows of Opportunity

• Before informal supports dwindle
• Before material possessions are gone
• Before becomes resigned to institutionalization
• Before supports are developed inside the facility
• Before hope is gone

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Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

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Technical Assistance

• Roll-out Meetings
• Monthly Regional TA Calls
• NHT Technical Assistance Guide
• NHT Conference in October
• Regional Housing TA Meetings
• NHT E-mail Address ra-nht_at_state.pa.us
• State Staff
• PDA Tim Hoskins, [phone]
• DPW Kim Kramer, [phone]

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Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

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AAA NHT Responsible for transition services and
supports to over 60 consumers actively works
with each consumer to complete a successful
transition
Coordination between LTL and NHT activities

• Long Term Living Counselor
• Provide information and guidance to consumers
• Ensure that all options are explained fully
• Enable consumers to make informed choices about
  where and how they receive LTL services

Local Collaboration Shares knowledge, expertise,
and resources to support successful transition
case conferencing around difficult transitions
other activates depending on local arrangements
DPW NHT Partners Responsible for transition
services and supports to under 60 consumers
actively works with each consumer to complete a
successful transition