enhanced nursing home transition nht collaborative partners regional meetings august 2006
TRANSCRIPT
Enhanced Nursing Home TransitionEnhanced Nursing Home Transition
NHT Collaborative Partners
Regional Meetings
August 2006
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GoalsGoals
Provide a context for discussing change in Pennsylvania’s Long Term Living system
Provide key information for staff to support Enhanced Nursing Home Transition
Susan Reinhard Co-Director Community Living Exchange Rutgers University July 12,2006
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Improving Access to LTC OptionsImproving 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 PictureThe Pennsylvania Picture
Three Imperatives to Balance the Long Term Living System in PA
– Demographic trends
– Consumer choice
– Fiscal challenge
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Pennsylvania’s ProgressPennsylvania’s ProgressShare of NCBS Waiver users has increased since 2002-03Share of NCBS Waiver users has increased since 2002-03
Pennsylvania's LTL Balance
81% 79% 75% 74% 70%
19% 21% 25% 26% 30%
0%
25%
50%
75%
100%
FY 02-03 FY 03-04 FY 04-05 FY 05-06 FY 06-07
Year
Per
cen
t
Nursing Facilities Waiver Programs
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Enhanced Nursing Home TransitionEnhanced 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
Enhanced Nursing Home TransitionEnhanced Nursing Home Transition
NHT Collaborative Partners
Regional Meetings
August 2006
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Minimum Data Set (MDS) Minimum Data Set (MDS) ReportsReports
Front Door Bi-Monthly Admissions
Run Date: 8/1/2006
County: Lancaster
Total Residents: 163
Facility NameMA
Number<=30 Days
31 to 90 Days
Long Term
UN- CER
TAIN DEM-ENTIA
Under 60
Over 60 Total
AUDUBON VILLA100750738
0004 0 0 0 3 1 0 3 3
BEVERLY MANOR OF LANCASTER
1015519170001 0 0 0 1 0 0 1 1
BRETHREN VILLAGE100126248
0003 1 0 4 1 1 0 6 6
CALVARY FELLOWSHIP HOMES, INC
0007452430001 0 1 1 3 2 0 5 5
TOTAL 26 18 44 75 50 6 157 163
Provider NameFirst Name
M I
Last Name
AGE
<=30DAYS
31 To90
DAYS
LONG
TERM
UNCERTAIN
DEMENTIA
<60 Tracker # Referral
AUDUBON VILLA Carson Busses 88 0 0 0 1 0 0
AUDUBON VILLA Earl Lee Byrd 85 0 0 0 1 0 0
AUDUBON VILLA Patty Cakes 90 0 0 0 1 1 0
Run Date 08/01/2006Run Date 08/01/2006County: LancasterCounty: Lancaster
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Lancaster MDS InformationLancaster 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 – 0Long Term – 0Uncertain - 3
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Unified Data TrackingUnified 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
Enhanced Nursing Home TransitionEnhanced Nursing Home Transition
NHT Collaborative Partners
Regional Meetings
August 2006
Comparison of working with a Comparison of working with a newly admitted resident vs. long newly admitted resident vs. long term residentterm resident
Susan Reinhard Co-Director Community Living Exchange Rutgers University July 12,2006
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Myth: Most People in Nursing Myth: Most People in Nursing Homes Need to be ThereHomes 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 Generalizations regarding newly admitted residentsadmitted 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 Generalizations regarding long term residentsterm residentsInformal supports have relaxed or
gone awayLoss of material possessionsResignation to institutionalizationDependent upon NH staff, schedule,
supportsMay be in grief/loss cycle
Change = Loss = GriefChange = 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) Kubler Ross (1969)
Grief/Loss cycle– Denial– Anger– Bargaining– Depression– Acceptance
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Roller coaster ride of the Roller coaster ride of the grief/loss cyclegrief/loss cycle
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Barriers to NHTBarriers to NHT
Irrational fears/thoughtsExternal influences/institutional biasLack of supportsHousing issuesLack of knowledge regarding
availability of community servicesAgeism
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How to Address BarriersHow 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 OpportunityWindows of Opportunity
Before informal supports dwindleBefore material possessions are
goneBefore becomes resigned to
institutionalizationBefore supports are developed
inside the facilityBefore hope is gone
Enhanced Nursing Home TransitionEnhanced Nursing Home Transition
NHT Collaborative Partners
Regional Meetings
August 2006
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Technical AssistanceTechnical Assistance
Roll-out Meetings Monthly Regional TA Calls NHT Technical Assistance Guide NHT Conference in October Regional Housing TA Meetings NHT E-mail Address: [email protected] State Staff:
– PDA – Tim Hoskins, (717) 783-6207
– DPW – Kim Kramer, (717) 787-8097
Enhanced Nursing Home TransitionEnhanced Nursing Home Transition
NHT Collaborative Partners
Regional Meetings
August 2006
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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
AAA NHT Responsible for transition services and supports to over 60 consumers; actively works with each consumer to complete a successful transition
DPW NHT PartnersResponsible for transition services and supportsto under 60 consumers; actively works with each consumer to complete a successful transition
Local CollaborationShares knowledge, expertise, and resources to support successful transition; case conferencingaround difficult transitions; other activatesdepending on local arrangements
Coordination between LTLand NHT activities