Connection to Community Living Frequently Asked Questions for Nursing Home Staff 2013

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Connection to Community Living
Frequently Asked Questions for

Nursing Home Staff


State of Wisconsin

Department of Health Services

Division of Long Term Care

Connections to Community Living (CCL)

Frequently Asked Questions for Nursing Home Staff
This document provides responses for nursing home staff to frequently asked questions related to the Connections to Community Living Initiative (CCL).

  1. What is Connections to Community Living (CCL)?

The Wisconsin Department of Health Services and local Aging and Disability Resource Centers (ADRC) are working with older adults and people with disabilities who live in nursing homes, state Centers, and ICFs-ID to provide information about community living. The Connections to Community Living (CCL) initiative helps older adults and people with disabilities understand that they have a choice as to where they will receive their care.

Through Connections to Community Living, an individual learns about options for living in a home environment while receiving the services needed to be healthy and safe. The person-centered planning process includes “an exploration with the person’s preferred living situation and a risk assessment for the stability of housing and finances to sustain housing as indicated.” Persons who are living in institutions are encouraged to choose the least restrictive and most integrated setting. They may have discussed this with the facility social worker, the MDS coordinator, staff from the ADRC or a Community Living Specialist who works with the CCL program.
The Connections to Community Living Project is intended to help residents explore options, discuss with guardians and other family members a resident’s preferences, and work with residents and their families to choose among the long term care options available to them. CCL connects individuals and their families to the ADRC for options counseling and, if eligible, public long term care benefit programs.
The CCL Project assists with identifying and reducing barriers to relocation, such as income and housing challenges, and may continue to provide support in the person-centered planning process to ensure that a resident’s preferences are expressed within the interdisciplinary team (IDT).
The CCL Project works with all residents in an institution who are interested in community living. This includes, for example, residents who have recently been admitted to a facility, either for rehabilitation services, respite, or skilled nursing services, as well as residents who have been living in a facility on a long-term basis. It also includes all residents regardless of payment source (i.e. those who are recipients of Medical Assistance and/or Medicare as well as those whose expenses are paid for with private funds or insurance). For those residents receiving Medical Assistance, CCL services are available whether or not a resident is a member of an Managed Care Organization (MCO).
As needed, the CCL Project works with the facility discharge planner and social worker, the ADRC options and enrollment counselor, the care manager or other IDT staff, and the family and other individuals and agencies assisting the individual.

  1. Who is eligible to participate in this program?

Anyone who currently lives in a Wisconsin licensed nursing home or facility for the intellectually or developmentally disabled is eligible to participate in this program. There are some public funding restrictions depending on which county the nursing home is located in.

  1. Why is this initiative being implemented?

Consumer advocates, states, and the federal government are advancing nursing home transition programs to help older adults and people with disabilities leave nursing homes and return to their homes and communities if they so desire. An essential component of nursing home transition efforts is assertive identification of the nursing home residents who prefer a home- or community-based setting rather than the nursing home. One potential way to help identify individuals who want to transition is better use of the Long Term Care Minimum Data Set (MDS); especially Section Q that addresses discharge potential and overall status of the resident. Using this process, the nursing home staff will regularly ask the resident if they would like to talk to someone about returning to the community, since resident needs and the services available in the community may change over time.

  1. Who are the Community Living Specialist (CLS) and what is their role?

The overall responsibility of the Community Living Specialist (CLS) is to:

  • provide quality outreach to nursing home residents and providers;

  • develop an outreach plan designed to identify and engage residents who are interested in relocating to the community;

  • provide outreach to residents of nursing homes in assigned service area and develop working relationships with key facility staff;

  • collaborate with nursing home staff to identify potential relocations;

  • collaborate with discharge planners on addressing barriers to relocation;

  • advocate on behalf of residents who encounter barriers to relocation;

  • connect residents with advocacy organizations, such as ombudsman programs, as necessary;

  • provide formal education and training to nursing facility staff about community living alternatives and options for addressing health and safety in community based settings;

  • provide informal and formal opportunities for residents to learn about community options and ways to overcome barriers associated with transition;

  • make presentations to resident councils and other groups as assigned;

  • develop a process, in collaboration with ADRCs in assigned service area, for receiving MDS Section Q referrals;

  • work with the nursing homes to understand the purpose, requirements and the process for making referrals;

  • work with private pay nursing home residents;

  • successfully complete options counseling and other relevant training required to perform duties;

  • as appropriate and in collaboration with the nursing home, work with individuals (and their representatives) who have been admitted to the nursing home for rehabilitation or short-term stays, ideally while the individual has a home, apartment or other community residence;

  • for people who will be discharged as private pay, work with discharge staff in the nursing home to provide information, help overcome barriers and ensure that a safe, sustainable discharge plan is in place;

  • provide options counseling as appropriate or required beyond typical discharge planning;

  • follow up with people shortly after discharge to the community to see how they are managing and whether there is additional information or assistance that would be helpful and

  • collaborate and coordinate with Aging and Disability Resource Centers, according to policies and procedures developed locally, to ensure timely referrals between the ADRC and the Community Living Specialist.

  1. Who should I talk with if there is a resident interested in moving to the community?

You should first talk with your local Aging and Disability Resource Center (ADRC). A staff person from the ADRC will come to visit the resident and their family member at the nursing home to talk about options. More information about the role of an ADRC can be found at the ADRC website.

  1. So if the resident decides they want to move back to the community then what are the next steps?

The next steps depend on the resident’s payer status.

If the resident currently uses private funds or insurance to pay the nursing home, then the resident would work with the social worker from your facility who would get them into contact with the local ADRC (see question #5). The ADRC and the nursing home social worker would research the best options to meet the resident’s current and on-going needs in the community.
If the resident requires public funding, and your nursing home is in an area served by Family Care or IRIS, then after meeting with a representative of the ADRC (see question #5) the resident would enroll in one of the managed care organizations. The resident would then work with an interdisciplinary team with the managed care organization to explore the best options to meet current and on-going needs in the community. Staff of the nursing home would be consulted as you are most familiar with the resident. More information about Family Care and the role of the managed care organization can be found on the IRIS or Family Care website.
If the resident requires public funding, and your nursing home is in a non-Family Care County, then after meeting with a representative of the ADRC (see question #3) the resident would meet with a care manager from the county department of human services. Together they would explore the best options to meet the resident’s current and on-going needs in the community. Staff of the nursing home would be consulted as you are most familiar with the resident. More information about Waiver County Services and the roll of the care manger can be found at:
In all these scenarios the goal will be to move the person to a home or an apartment with supports if that is feasible. The team will look into available services (like help with personal and medical care) and programs that may help pay for needed services when appropriate. They’ll also look into housing options and/or home modification services.

  1. Through this initiative, can a resident move to an assisted living community?

A primary goal of Wisconsin’s long term care programs is to support people to live in their own homes or with family. Services in facilities are only provided as a last resort. If a resident requires public funding, there are a number of conditions that would have to be met for the resident to relocate to an assisted living facility such as a Community Based Residential Facility (CBRF). These conditions ensure that home-care and residential options are explored and discussed with the individual, that the person prefers an assisted living setting over other settings, that it is cost effective, and that it is a quality setting.

  1. Can a resident who has started a plan to leave the nursing home change his or her mind if and stay in the nursing home?

Absolutely. This initiative is about resident choice and trying to eliminate barriers to a move for those interested. A resident decides whether or not to start the plan to leave the nursing home and can change that decision at any time. Staff administering the MDS assessment will periodically ask the resident if she or he wishes to talk with someone about returning to the community.

  1. What is my role as a social worker of the nursing home related to this initiative?

You have an extremely important role in discharge planning. Discharge planning should begin as soon as the resident enters the facility. The ultimate goal for some residents may involve transfer to another facility, admission to alternative treatment programs or returning home to an independent level of functioning. Whatever the ultimate goal, discharge planning is a critical part of the resident’s overall plan of care and can be a useful tool in determining progress towards the goals identified in the care plans. The social worker should always encourage and support the resident’s effort to function at the highest possible level. For those residents leaving the facility to return home or to placements in other facilities, discharge plans should focus not only on the immediate care needs of the resident but also on the transition and relocation needs of both the resident and their family or support system. These may include visits to the new facility, family orientation or training to the care needs of the resident or introduction to home-based caregivers. Discharge planning should be an interdisciplinary assessment process that includes and encourages physician, dietary, therapy, nursing, and family involvement. The plan should be specific, relevant and individualized to the overall needs and abilities of each resident.

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