MFP: What We Are, Where We’ve Been, Where We are Going

1. MFP: What We Are, Where We’ve Been, Where We are Going

2. What is MFP? A beautifully simple concept…. An opportunity to support people to transition into their homes and communities.

4. MFP: 2 Primary Purposes Support the transition process Systems change: Increase Home and Community Based Services Eliminate Barriers Continued Provision of Services Quality Improvement If we only support people to transition, we’re only doing half our job.

5. MFP – Individual Level The MFP Demonstration Project willtransition qualified individuals from qualified inpatient facilities to qualified residences in the community. What does this mean?

6. MFP – Individual Level “Qualified Individual” Currently track three population groups: people with physical disabilities, people with I/DD and older adults. Currently resides and has resided for at least three months in an inpatient facility (nursing facility, developmental center, ICF/MR, hospital) Is receiving Medicaid benefits for inpatient services furnished by the inpatient facility, and Continues to require the level of care provided by the inpatient facility.

7. MFP – Individual Level Qualified facilities include: Nursing facilities Developmental Disability Centers (State Operated Centers) Intermediate Care Facilities for Persons with I/DD Acute Care Facilities PRTFs NOT Assisted Living Facilities

8. MFP – Individual Level Qualified residences in the community include: A home owned or leased by the individual or the individual’s family member, An apartment with an individual lease, with lockable access and egress, and that includes living, sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control, and A residence in a community-based setting in which no more than four unrelated individuals reside.

9. NC MFP’s Benefits to the Individual… CAP slot or PACE participation Project pays for first year, becomes regular CAP slot afterwards. Start up funding to assist in transitions Broadly construed: furniture, ramps, services (like therapeutic consultation, staff training, etc.) Additional case management Transition coordination support

10. Why Do Transitions Matter? Positive Outcomes of Transition Work

11. The Statistical ReasonsSource MPR Field Report, Number 6, May, 2011

13. The Financial ReasonsQEHO August, 2012

14. . The Human Reasons

15. 2012: A Year In Review

16. Our 2012 Benchmarks

21. The Direction We Set in 2011

22. Our Goals We Set for 2012

23. “Ensuring the Quality of the Transition Process”—Strengthening the Transition Coordination Process • YEA! Expanding transition coordination by now contracting with three Centers for Independent Living. • MFP Transition Coordination now threshold requirement for accessing all I/DD MFP slots. • MFP Transition Coordination practices, particularly risk mitigation elements, now embedded into DOJ Settlement.

24. Transition Coordination: What We’ve Learned • Intent has always been to try our current practices and reassess in 2013. • Our transition practices create a much stronger transition mechanism for individuals with significant support needs. • Our practices may sometimes “get in the way” of straightforward transitions. • Strong, contractual relationships with transition coordination function makes for clearer practices. • Creating a voluntary option for local case management entities has revealed some wonderful transition coordinators but also creates really spotty and sometimes a confusing lack of coverage.

25. “Exploring Expansion into Supporting People with Severe and Persistent Mental Illness” What We’ve Done: • 2012: We’re supporting eligible kiddos to transition out of psychiatric residential treatment facilities. • Must also meet I/DD requirements right now. • 2012: Supporting eligible individuals with I/DD who are in the psychiatric hospitals to transition. • Must also meet MFP “IMD” criteria—under 22 or 65+

26. Supporting People with Mental Health Support Needs: Lessons Learned. • “Hidden in plain sight” • We estimate that about 20% of our under 65 SNF population has a mental health or substance addiction support need. • 2012: Better Screening, Better Linkage, Better Follow Along • Big thanks to DMA and DMH mental health colleagues! • “Point of Contact” Partnerships with MCOs.

27. Expansion into SubWaiver Transition Efforts • Working to meet the needs of indiviudals who may be in nursing facilities but do not require waiver-level of service. • More intensive follow along • Increased coordination with CCNC.

28. 2012: The Year of StoryTelling • Working to Address “Best Kept Secret” Challenge. • MFP Outreach Committee launched • Everyone agrees: real “homegrown” stories, told by people directly, is best. • Brochure revised. • Website Revised

31. The Work Left To Do • Potential population far, far larger than transitioned population. • Want to support/fund “mama to mama” discussions within I/DD community. • Strengthen our speakers’ pool. • Difficult to grow without automation • Exploring how to best automate many of our application and tracking systems.

32. MFP Rebalancing Fund • Budget climate delayed getting Fund established, but it is! • To date: • Three Priorities: • Housing • Family Caregiver Support • ICF-Voluntary Conversion

33. Systems Change: The Role MFP has Played in 2012 • Providing “real life” information about what works (and what doesn’t!) in transition support. • Advising DOJ Settlement implementation efforts on transition practices. • Supporting CAP DA’s waiver renewal, recommending service revisions to better meet needs of transitioning individuals. • Served as 811 Grant point of contact within DMA. • We continue to be “the Bank” for systems change efforts like the Local Contact Agency function. • Quick LCA update.

34. Where We Didn’t Make As Much Progress As We Would Have Hoped • ICF-IDD Voluntary Conversion. • O’Berry Transitions • Supporting people to have strong information and linkages to employment. • Supporting people to strong information and access to assistive technology. • Eligibility system. • “Growing Pains” • Our technology of faxes, excel spreadsheets and email can no longer keep pace with our increasing volume. • We need a data system that can ensure MFP staff and all transition coordinators can enter and track information in an efficient way. Period.

36. And Still in the Distance… • How do we fit into our state’s Olmstead strategy? • How do we most effectively address institutional biases codified in statute? • How do we build a plan that most effectively rebalances our long-term care systems?

37. Lessons Learned…. • Do not rush a transition. Period. • State systems unrelated to services are often big challenges (i.e. HR, contract, procurement). • Trust in people’s ability to work together to create good outcomes: Roundtable, Advisory Groups, Learning Communities. • Competing priorities and initiatives make inter-agency collaboration challenging at times and yet, people have given wonderful support to this effort.

38. A Collection of Our Words of Wisdom… • “Just keep swimming” • Dorie the Fish, Finding Nemo • “Don’t rush, don’t stop.” • Brought to us by Linda Kendall Fields • “To go fast, go alone. To go far, go together.” • “African” Proverb

39. 2013 Benchmarks • Older Adults and People with Physical Disabilities: at least 100. • People with I/DD: at least 30. • Considerations for kiddos in PRTFs, CAP C • Considerations for I/DD-MI

40. CY2013 • Meeting our benchmarks • Strategic Planning regarding benchmarks after 2014. • MCO transition practices • Leveraging DOJ efforts • Training • Data collection • Outreach • Assistive Technology • Transition Coordination function • Strengthening Our Mental Health Linkages • Revising Operational Protocol

41. Save The Date! MFP Roundtable: February 8th