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This document outlines the strategies developed and implemented by Public Service Consultants to facilitate the transition of residents from nursing facilities to community living. It covers the characteristics of good peer outreach and support staff, outreach to professional stakeholders, peer outreach workflow, tools used in the peer network, outreach opportunities, challenges faced, support opportunities, and lessons learned. The focus is on effective communication, collaboration, and cooperation to ensure successful transitions for residents. Contact Public Service Consultants at (410)929-7258 for more information.
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Stakeholder Meeting October 1, 2013 Money follows the person
Where We Started • A Mission • 32 Nursing Facilities • A Plan Public Service Consultants (410)929-7258
What We Found Public Service Consultants (410)929-7258
Characteristics Of Good Peer Outreach & Support Staff • Peer Facilitators will have multiple roles including • Being an effective peer outreach & support staff member • Sharing personal experiences about institutional living and transition process; • Being an effective peer by building relationships with residents and NF staff • Being knowledgeable of community resources and supports • Being an active listener Public Service Consultants (410)929-7258
OutreachTo Professional Stakeholders • Options Counselors and Options Counseling Organizations, Social Workers, Nursing Facility Staff, Health Care Coordinators, Baltimore City Ombudsman's Office • Contact nursing facilities stakeholders and: • Held 1st one-on-one meeting with Image Center (Living At Home Waivers) in Fall 2012 • Held 1st information session with Ombudsman Program Spring 2013 • Held informational session Maryland Disabilities Law Center in Winter 2012-2013 Public Service Consultants (410)929-7258
Peer Outreach Workflow LTSS Tracking System Public Service Consultants (410)929-7258
Peer Support Work Flow LTSS Tracking System Public Service Consultants (410)929-7258
Outreach to Individuals • Key Elements of Outreach to Residents • Verify informal referral sources; • Identify and prioritize facilities with regard to scheduling; • Make referrals for Options Counseling and /or provide peer support; Public Service Consultants (410)929-7258
Tools We Use In & Out Peer Network Flyer Local & State Literature Door Hangars MFP Maryland PSC Internal Database Public Service Consultants (410)929-7258
Outreach Opportunities • Outreach in group settings; strength in numbers; • Don’t underestimate “word of mouth”; • Baltimore City citywide presentation opportunities; • Mass marketing of MFP • Peer networking among residents and staff; • Some NF’s and stakeholders seem threatened; • Confusion among residents and professional stakeholders; Outreach Challenges Public Service Consultants (410)929-7258
Support Opportunities • Coordinated support to multiple NF residents with same or similar barriers; • Coordinated, scheduled support to nursing facilities; • Increased participation among stakeholders to address principal barriers to transition; • Residents ambivalent about role of Peer; • Residents may not see support from Peer as tangible; • Decentralized support / Information overload; • Verifying results (outcomes and placement); Support Challenges Public Service Consultants (410)929-7258
Lessons Learned • Cultivate relationships; • Clarify misinformation in writing when possible; • Capture everything in LTSS system; • Over communicate; • Ask case managers, counselors, stakeholders about residents already willing and waiting to transition from NF’s. Residents are waiting on us. (Smile) Cooperation Coordination Communication Collaboration Chaos