We at ASCM are excited to announce our authorization and plan to begin serving a new Pennsylvania Department of Human Services (DHS) pilot program that will provide direct support of eligible individual’s seeking to transition from a Nursing Home Facility back to their homes and communities. The program is branded “Nursing Home Transition,” with the acronym, “NHT.”
The spirit of the program will be to hyper-focus support coordination resources to overcome all of the most common barriers an individual may face during the aforementioned transition process. Our specialized NHT team will liaise with nursing home social workers and discharge planners to develop action step planning, ensuring all the necessary pillars are in place to ensure a successful, healthy and empowering transition to one’s designated home environment of their choice. The team will be supervised by a highly qualified NHT Manager, who will develop partnerships with PA nursing homes to better facilitate cross-agency communication, engaging all members of an individual’s treatment team, including his or her family members.
We believe it goes without saying that our core philosophy at ASCM, the reason we exist, is to address the very simple and very human fact that 95% of individuals residing in nursing homes or other long term care facilities deeply desire to return to their own homes and own communities, and that this wish should be of paramount importance when developing long term care strategies. A senior citizen has both the right and resources to “age in place,” to receive treatment and care in the comfort of their own home and individuals with a disability should be given the supports to be a part of a community where they can become “empowered through independence.”
We at ASCM have already designed our operational infrastructure for this excellent new program, including the hiring of a seasoned NHT Program Manager, who’s profile I will be highlighting in a blog post coming in the next several weeks. The program will officially start on 3/1/17 and we hope that anyone with any questions will reach out to us or DHS.
From DHS’ official website:
“The NHT Program was developed to assist and empower consumers who want to move from a nursing facility back to a home of their choice in the community. NHT also helps the Commonwealth rebalance its long-term living systems. When given choice, an overwhelming number of people say they want to age in place in their homes rather than in institutions. Yet, in publicly funded programs, the bias has always been toward institutional care. NHT provides the opportunity for individuals and their families or caregivers to be fully informed of all long-term services and supports options, including the full range of available home and community-based services (HCBS). Through the NHT program, individuals can receive the guidance and support they need to make informed choices about their long-term services and supports. The program assists individuals in moving out of institutions and eliminates barriers in service systems so that individuals receive services and supports in settings of their choice.”
Goals and Objectives of the NHT Program:
• Help rebalance the long-term living system in Pennsylvania so that people have a choice of where they live and receive services. • Enhance opportunities for individuals to move to the community by identifying individuals who wish to return to the community. • Identify and overcome barriers that prevent transitions. • Empower individuals so they are involved to the extent possible in planning and directing their own transition from a nursing facility back to a home of their choice in the community. • Develop the necessary infrastructure and supports in the community. • Expand and strengthen collaboration between aging and disability organizations to provide support and expertise to the NHT Program. • Educate individuals and families about long-term living services.
WHO TO CONTACT?
If you would like to apply for a Home and Community Based Services Medicaid Waiver, contact the Pennsylvania Independent Enrollment Broker (IEB) at: 1-877-550-4227. You may also begin your application for benefits online using the COMPASS website.
If you need help but are not sure who to contact, there are several ways to access information and referral services:
ONLINE by using the convenient online Information and Referral Tool
CALL the PA Link to Aging and Disability Resource Center toll free at: 1-800-753-8827
Contact your local Link partner agency, such as the Area Agency on Aging (AAA) or Center for Independent Living (CIL) and ask to speak to an “options counselor.”
If you or a loved one is interested in returning to the community from the nursing facility, you may initiate the nursing home transition process by either: • Contacting nursing facility staff to initiate a Nursing Home Transition (NHT) referral OR • Contacting an available NHT Coordination Agency directly. Locate your county using the following list to identify an NHT Coordination Agency to assist you in exploring the available options to transition home.
NHT Coordination Agencies
If you have any difficulty or need assistance in this process, you may contact the Office of Long Term Living Division of Transition and Diversion at 1 (800) 833-5196.
Preserving Existing Housing
If you still have appropriate housing to return to and expect to be able to be discharged from the nursing facility within 180 days, you may be eligible to set aside some of your income to use towards upkeep of your housing through the Home Maintenance Deduction. Eligibility for the Home Maintenance Deduction is determined by the County Assistance Office. The nursing facility social worker can assist you in the application process.
Sometimes existing housing is no longer safe or accessible. If you have a home but cannot return to it as-is due to a change in your condition, you may be able to get help with modifying or adapting your home to make it accessible. Many of the Home and Community Based Waivers include funding for home modifications.
LOCATING NEW HOUSING
If you do not already have appropriate housing but you wish to return to the community, one of the first steps to transition is to locate affordable, accessible housing. PAHousingSearch.com is a searchable database that can assist you in finding appropriate housing.
In order to complete applications for housing and/or benefits, you may need to provide documents verifying certain important information. Below is a list of commonly required documentation. Included in the list below, where available, are hyperlinks to sites where you can request copies of documentation.
Proof of earned and unearned income
Proof of resources, e.g. bank accounts, stocks, etc.