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Massachusetts “Bridges” to Community
Agenda
Project OverviewWho is eligible?What is the processQuestions & Feedback
Project Overview
What is Mass “Bridges” to Community Project?
Many people living in nursing homes do not know of the available alternatives, services and supports to live independently in the community.
“Bridges” is a federally funded project that helps assist people in nursing homes get the supports they need.
Systems Change for Community Living Grants
Four Types• Nursing Facility Transitions
Grant• Real Choice Systems Change• Community Integrated Personal
Assistance Services and Supports• National Technical Assistance
Exchange for Community Living
In 2001 $64 Million was awarded to 37 states and 1 territory by U.S. Centers for Medicare and Medicaid Services
Nursing Facility Transitions GrantThe “Bridges” Project was awarded $770,000 for 3 years
Cross-agency, cross-disability project• Executive Office of Health & Human
Services,• Executive Office of Administration
and Finance (DHCD, MassHousing, CEDAC),
• Executive Office of Elder Affairs,• Department of Mental Retardation,• Massachusetts Rehabilitation
Commission,• Division of Medical Assistance, • Department of Public Health, • Department of Mental Health
Department of Mental Retardation is grantee
“Bridges” Project Goals
Assist eligible individuals to transition from nursing homes to community living
Identify and address service gaps, barriers and challenges facing individuals in their move to community living and their success in remaining in the community.
Massachusetts Bridges to Community Project
Bridges Planning
Group
Grant Manager Bridges
Case Manger Service Coordinator Nurse Consultant Housing Consultant Administrative Assistant
Project Advisory
Board
Community Supports
Peer Mentors
State Housing Agencies
DMR Housing Director
Real Choices Leadership
Team
Interagency Steering Committee
Olmstead, ECBS, CMS Grants
BridgesProject
Director
Local Housing Auth.,
Realtors, Landlordse
tc.
CMS Nursing Facility Transitions Grant
Massachusetts Bridges to Community Project
Interagency Steering
Committee
Planning and Coordinating
Group
Grant Manager
Project Director
Case Manger/Service
CoordinatorNurse Consultant
Housing ConsultantAdministrative
Assistant
Project Advisory Board
Community
Based Supports
Peer Mentors
State Housing Agencies
DMR Housing Director
Family & Friends
Community at Large
Faith
Medical Services
Vocation/ Avocation
Advocacy
Transportation
HousingLeisure
Elder Services
Social Services
Community Long Term Care
Massachusetts Nursing Homes
Massachusetts has a total of 502 Nursing homes serving 54,000 individuals
There are 26 Nursing homes in the Worcester area serving about 2,800 individuals
“Bridges” plans to contact approximately 300 individuals• These individuals are
determined to need less than 110 minutes per day of skilled nursing care
The Bridges Team
“Bridges” core team:• Project Director
• Case Manager
• Service Coordinator
• Nursing Consultant
• Housing Specialists
Bridges Team Responsibilities
Introduce project and explore options with nursing home residents
Develop individual plan with interested Eligible individuals
• Identify available community services & supports
Work with individual to implement plan
• Work with individuals to find a home, arrange services, and develop supports and connections.
Activities & Timelines
Year 1Year 1Year 1Year 1Year 2Year 2Year 2Year 2
Year 3Year 3Year 3Year 3
•Hire Staff•Identify Stakeholders•Obtain Space•Begin Outreach:• NF’s• CIL’s• MASS • Ombudsmen• Social Services• Local Community
•Identify & enroll participants•Transition Individuals•Establish Advisory Board•Peer Mentoring & Community Connections•Collect/review data•Share findings w/steering group
•Identify & enroll participants•Collect/review data•Share findings w/steering group•Evaluate Project
Examples of success in other States
Accessible, Quality Personal CareIntegrated Referrals: NF,
Hospital, CommunityAssistance with Transition CostsFinancial Incentives for
Community CareHelp NF’s Develop Community
ServicesComprehensive Housing
Development
Identifying Participants
Who is Eligible?Persons Who….
• Live in a nursing home in or around Worcester
• Are MassHealth eligible
• Need approximately 110 minutes or less per day of skilled assistance
• Express desire to live in community
Identifying Participants
Identifying Participants
In our experience, there are two people in nursing homes to ask about a person returning to the community:• Consumer
• Key Nursing Home Staff
Identifying ParticipantsWho better to ask?
Consumer most often knows exactly what services and how much of each the require and can tell a care provider how they want it done.
Identifying Participants
Key Nursing Home Staff• May know the resident(s) who
want to leave
• May be able to coordinate transitioning services from nursing home end
• May be knowledgeable of family and can advocate on consumer’s behalf
• Have knowledge important to planning supports
Barriers to Community Transition
Fear of the Unknown
Lack of Personal Supports
Low Expectations
Loss of Income
Unaware of Available
Community Resources
Lack of Community Resources
Case Management (someone to help with planning your transition)
Help with securing available resources (personal care, health care, money saving options)
Help with arranging housing (assist with finding accessible affordable housing, arranging utilities)
Peer counseling and mentoring (someone to talk to who has already moved back to the community)
Community connections (contacts at local churches, clubs, businesses, health services)
Transitional supports (help with getting basic furniture, adaptive equipment, security deposits for utilities and rent, etc.)
Bridges will provide…
ProcessIndividual Meeting with Project Staff
Exploring your options (looking at housing, talking to mentors)
Meetings with others of your choice
Describing your preferences and needed
supports
Developing your transition plan
Making it happen
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