MONEY FOLLOWS THE PERSON Stakeholder Meeting October 1

MONEY FOLLOWS THE PERSON Stakeholder Meeting October 1, 2013

Where We Started A Mission 32 Nursing Facilities A Plan Public Service Consultants (410)929 -7258 2

What We Found Public Service Consultants (410)929 -7258 3

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 4

Outreach To 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 1 st one-on-one meeting with Image Center (Living At Home Waivers) in Fall 2012 Held 1 st information session with Ombudsman Program Spring 2013 Held informational session Maryland Disabilities Law Center in Winter 2012 -2013 Public Service Consultants (410)929 -7258 5

Peer Outreach Workflow • Send introduction letter to NF Staff; • Call and schedule 48 hours in advance of all site visits; • Meet with nursing facility staff Nursing Facility • Visits to NF events and/or activities; • Knock before entering resident room; • Announce who you are and why you are there; • Leave MFP information and obtain resident info. Resident LTSS Tracking System Ombudsman Information • Work with Ombudsman to maintain and schedule networking opportunities to further the understanding about MFP and Peer Outreach and Support; • Maintain schedule of NF actiivties; • Citywide related opportunities to present MFP Public Service Consultants (410)929 -7258 6

Peer Support Work Flow • Verify that resident has an interest in transitioning from NF; • Peers refer residents for peer support • Make inquiry to Options Counselor, LAH Waiver and NF staff regarding residents that have expressed an interest in transitioning from NF’s; • Call and schedule 48 hours in advance of all site visits to meet with NF residents; • Discuss and indentify barriers to transition; Professional Stakeholders NF Resident • Meet one-on-one with residents to discuss process and share perspective of transitioning and the possibility of community living. • Identify opportunities for further support; LTSS Tracking System Ombudsman Information • Maintain two way communication to inform and learn about local updates in major changes to NF’s that effect Peer work (staff changes, NF closings, management changes, unmet resident needs, etc. • Remain plugged-in, updated and resource rich; • Touch base with Options Counselor and LAH Waiver staff ; • Review data in tracking system for accuracy; • Remain current on changes to the NF that effect support needed for NF residents; Public Service Consultants (410)929 -7258 7

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 8

Tools We Use Local & State Literature In & Out Peer Network Flyer 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; Outreach Challenges Some NF’s and stakeholders seem threatened; Confusion among residents and professional stakeholders; Public Service Consultants (410)929 -7258 10

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; Support Challenges Residents ambivalent about role of Peer; Residents may not see support from Peer as tangible; Decentralized support / Information overload; Verifying results (outcomes and placement); Public Service Consultants (410)929 -7258 11

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) Chaos Cooperation Coordination Communication Collaboration