Since 2001, when Texas began the state Money Follows the Person (MFP) nursing facility transition initiative, called Promoting Independence, more than 12,000 people have been moved from nursing homes to other residential settings. Currently there are approximately 5,000 people who are enrolled in the Texas MFP program. Of those persons currently in the program:
- sixty-four (64) percent are women
- forty-six (46) percent are living with a family member
- twenty-eight (28) percent are living in an assisted living setting
- twenty-two (22) percent are living alone in a home or apartment.
In terms of age ranges:
- four (4) percent are under the age of 22
- seven (7) percent are 22 to 44 years old
- twenty-seven (27) percent are 45 to 64
- thirty-one (31) percent are 65 to 79 years old
- twenty-two (22) percent are age 80 to 89
- seventy-seven (77) percent are 90 years old or older.
In addition, the program has helped 11 people that were over the age of 100 leave a nursing home to live in a different setting.
When the MFP Promoting Independence program began in 2001, the state licensing and regulatory agency, under the Department of Aging and Disability Services, sent a letter to every Medicaid-eligible nursing home resident, describing the program and the opportunity to leave the facility and live in the community. Residents were informed that Medicaid would continue to pay for their care, as long as the cost was less than the cost of care in the nursing home.
There are six "relocation" contractors across the state, providing transition services to residents, including assessment and case management services. Referrals to the MFP program come from a variety of sources, including ombudsmen. In 2006, on average, each of the 28 local ombudsman programs referred between 15 and 20 people to the program. Currently, the majority of referrals are by relocation contractors visiting with nursing home residents in response to Minimum Data Set (MDS) information that identifies specific residents who have stated that they want to leave the nursing home and live in a different community setting.
When a resident is determined eligible for the MFP program, a caseworker assists the resident with accessing the needed services. Approximately 94 percent of the elderly and persons with disabilities who transition out of nursing facilities under the MFP program use community based alternative (CBA) waiver services. A consumer directed service approach is beginning to be used, so the client may hire and fire the home care worker of his or her choice.
When the Texas Promoting Independence initiative began, the state ombudsman coordinated with the Centers for Independent Living to train local ombudsman program managers on nursing facility transition, the Olmstead decision and how the Texas MFP program would work. Local ombudsmen were then encouraged to train local program staff and volunteers using the model provided at the state training.
Ombudsmen see their role as an identifier and an initiator of the process, first and foremost, but also as educators and communicators. We play an important role in follow-up and follow through, advocating at different levels of the process as problem solvers. It's a pretty natural fit for us in Texas.
-Patty Ducayet, Texas State Ombudsman
According to Ms. Ducayet, local ombudsmen believe that their most important role in connection with the Promoting Independence initiative is as an identifier and referral agent. Local ombudsmen feel that identifying residents who might be candidates for leaving the nursing home and living elsewhere is something they can easily do in the course of their advocacy activities in nursing facilities. Generally this happens in one of two ways; either a resident tells the ombudsman that he/she wants to leave the nursing home, or ombudsmen, through their regular presence in nursing facilities, become aware of residents who seem like good candidates for leaving, either because of their level of functioning or because they express being unhappy with being in the nursing home. Ombudsmen believe that informing and educating residents about the MFP program is also a very important role of the ombudsman program.
When a resident expresses interest in transitioning out of the nursing facility the local ombudsman refers the resident to the relocation contractor. In Dallas, where Ms. Ducayet served as the local ombudsman, volunteers were given training on the MFP program so they would know to inform the local ombudsman if a resident expressed a desire to leave the facility or seemed like a good candidate for transition services.
Many local ombudsmen attend monthly meetings with regional relocation teams, which may consist of relocation specialists, waiver staff, advocates and sometimes, home care providers. Ombudsmen view their participation in these meetings as a key to the resident's successful transition back to the community by ensuring that the resident's voice is heard in the process. Living in contracted assisted living facilities is a community based alternative (CBA) option under Texas' Medicaid waiver. The ombudsman is someone who often knows the residents who are being assessed and considered for transition services, and also is familiar with the assisted living facilities in their regions and the types of residents they serve, so they can weigh in on the appropriateness of the transition for the resident.
Local ombudsmen often do a considerable amount of follow-up and follow through after making a referral. The relocation specialists assess clients to determine if they can live in a community setting, and work with the Medicaid Eligibility staff to apply for the CBA Medicaid waiver program. Ombudsmen frequently communicate with the resident about what will happen next in the process, and address any questions or concerns. Ombudsmen find that prompting of the different professional workers is necessary to avoid the process from stalling. The Texas Ombudsman Program only serves residents who live in nursing homes and assisted living facilities; they do not provide home care advocacy. So generally, when a resident leaves the nursing facility, the ombudsman's role is complete. If the resident is transitioned to an assisted living facility, which is a waiver option under the MFP program, then the ombudsman will likely follow-up with the resident as a usual advocacy activity.
When the MFP program began, some relocation specialists were obstructed, and in some cases escorted from the building, when they tried to visit nursing facility residents, because administrators were not familiar with their role. The ombudsman program helped educate facilities, and in some instances provided mediation, to help ensure the relocation specialists had access to residents. A letter to providers was written by the Department of Aging and Disability Services (DADS) to help support relocation specialists obtain access to residents, and ombudsmen and relocation specialists presented a copy of this letter when needed.
According to Ms. Ducayet, on a few occasions, local ombudsmen have served as "surrogate" relocators, buying the goods that people needed to live in their own apartment and finding apartments for residents who wanted to leave. These activities were not something that was asked of them, but happened because the process had started, and no one was taking the responsibility of seeing it through, so these ombudsmen jumped in and did this. In addition, of the 28 AAAs, only a couple have contracted to provide Transition Assistance Services (TAS) to people who are being relocated. This provides up to $2,500 per person for a one-time assistance to pay outstanding bills, purchase furniture, or pay for a security deposit. The CBA caseworker determines the amount, and the TAS contractor purchases the needed supplies for the client. This service creates a much more hands-on role for an ombudsman in the process, and is typically provided by other staff in the AAA or by other agencies, such as the Centers for Independent Living.
The Ombudsman program continues to have an important, though informal role in the nursing facility transition process, identifying residents and making referrals for transition assistance. No referral form is used, the ombudsman program is not mentioned in the written materials about the Promoting Independence initiative, and to date the program has not received any additional funding or resources for its activities.
The Texas Ombudsman Program has identified some issues and challenges relative to the Promoting Independence initiative, including those noted below.
- The transition process can take a long time. A common issue is that the transition process always takes several months (often 6 months or more), in part because the relocation contractors are few and sometimes far from the facilities and the residents that they serve.
- Conflicting philosophies. At times there has been a philosophical conflict between ombudsmen and relocation specialists. Some relocation specialists perceive transition as a mandate to free all people from the constraints of a nursing home, even though for some people a nursing home is their option of choice. Ombudsmen serve as an advocate for the resident, and sometimes the resident does not wish to move. Ms. Ducayet noted a couple of cases where residents had gone through all the hoops, were eligible for transition services and then decided to stay in the nursing home.
- Family resistance. Ombudsmen have expressed the importance of family involvement for a successful transition. Unfortunately, family members are sometimes very fearful and resistant to having their relative leave the nursing home environment because they view the nursing home as safe and the daily responsibilities of caring for the person are more than the family wants to or can provide.
- A reduction in assisted living beds. Assisted living is an option under the Texas community based alternative (CBA) Medicaid waiver. Unfortunately, the availability of those beds is beds shrinking as an increasing number of providers have decided to terminate their contracts with the waiver program. This has not only reduced the number of available beds for future MFP participants, but it has also meant the discharge of some residents currently in the MFP program who were transitioned out of a nursing home, putting them at risk of having to return to the nursing home.
- Affordable housing is scarce. The lack of affordable housing is a major barrier to residents wanting to transition back to the community.
- Finding home health providers for some persons with complex medical needs is an ongoing challenge. Some home health providers feel the risk of liability involved with providing care to persons with complex medical needs is too great.
- Some people are not safe living on their own. In very rare cases, there have been residents with a history of self-neglect. When they were transitioned back to the community their self-neglect behavior re-emerged, and they returned to the nursing home after a short time.
Ms. Ducayet commented that "We don't know how long people can live successfully outside of a nursing home, but any amount of time may be a great success to them, especially for people in their 90s and 100s. There is no timeframe to measure success. So, 'how will we measure success under the new CMS Money Follows the Person grant?' is still a question to be answered."
| It has been a very positive experience for the ombudsman program to dialogue with the services and programs that have primarily served adults with disabilities, because their philosophy is one that promotes independence for persons. It has taught the ombudsman program to think about person directed services, person directed care and choice, in a new way. -Patty Ducayet Texas State Ombudsman |
According to Ms. Ducayet, the Texas approach to nursing facility transition has been successful for a variety of reasons. The state chose to make it a priority. It saved the state money and it made sense in terms of providing people a choice in their lives. In addition, several state agencies that serve people that are aging and people with disabilities, recently consolidated, and that has had a positive impact. The merging of those two fields fits well philosophically with the goal of helping both older adults and persons with disabilities, maintain their independence and live in the setting of their choice.
