Home Again Program Money Follows the Person Demonstration Program - - PowerPoint PPT Presentation

South Carolina Department of Health and Human Services

Home Again Program

Money Follows the Person Demonstration

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Program Background

• The Money Follows the Person (MFP) demonstration,

established by Congress through the 2005 Deficit Reduction Act, provides state Medicaid programs the

• pportunity to help Medicaid beneficiaries who live in

long-term care institutions transition into the community and gives people with disabilities more choice in deciding where to live and receive long-term services and supports (LTSS)

• South Carolina’s Money Follows the Person

Demonstration is called “Home Again” Program

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Program Goals

• Increase the use of home and community-based services

(HCBS) and reduce the use of institutionally-based services

• Eliminate barriers in State law, State Medicaid plans, and

State budgets that restrict the use of Medicaid funds to let people get long-term care in the settings of their choice

• Strengthen the ability of Medicaid programs to provide

HCBS to people who choose to transition out of institutions

• Put procedures in place to provide quality assurance and

improvement of HCBS

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Program Updates

• The Home Again program stared it’s implementation in 2013
• The projected was scheduled to be ended by March 2016
• The state got an approval on extending the program until 2020
• The state got an approval on the 5 year budget in April 2016
• Will maintain the program after the grant ends under a regular

Medicaid authority

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Where we stand

• 44 MFP grantees (43 states and the District of Columbia)
• Over 63,000 transitioned from long-term institutional

setting to community residences as of December 2015

• Home Again (SC MFP) program have transitioned 76

individuals as of February 2017

• Estimated savings are over $3 Million per year

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Why Home Again?

• Most desired site of care
• Bypass waiver waiting list
• Address Housing needs
• Cost saving
• NH Daily Rate: $167
• Home Again Daily Rate: $42

Home Again Map as of February 2017

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Home Again Statistics

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 551 Home Again Referrals from Jan. 2013 to Dec. 2016  218 assessments were completed  Main Reasons for termination after assessment



Lack of family support



Difficulty in finding housing



Deteriorating health conditions



Lack of community resources to meet the medical needs

Program Eligibility

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To be eligible for the program, a person must:  Currently reside in a skilled nursing facility  Have been in the skilled nursing facility for at least 90 consecutive days*  Be on South Carolina Medicaid payment for at least one day before transitioning  Meet skilled nursing facility Level of Care * A person cannot count Skilled Rehabilitation Services via their Medicare Part A benefit as part of the 90 day requirement. The person can count hospital stays as part of the 90 days but the person needs to be admitted into the nursing facility at the time of transition (for at least one day).

How to get started

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1.

Complete a Referral Form at https://phoenix.scdhhs.gov/cltc_referrals/new

2.

Home Again staff will contact the nursing facility to get more information and send Eligibility Package

3.

The Nursing Facility will complete the package and fax it to Home Again at 803-255-8209

4.

A nurse consultant from the nearest area office will come out to conduct to Level of Care

Home Again Services

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 Home Again Services

 Transition Coordination  Expanded Goods and Services

─ Furniture up ─ Appliances ─ Initial Groceries ─ Security Deposits ─ Utility Deposits ─ Household items ─ Other non-covered items

Home Again program is assisting with housing and other issues in order to make successful transitions as well.

HCBS Qualified Services

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 HCBS Qualified Services can be overlapped with Home Again

Program

 HCBS Qualified Services are:

 Community Choices Waiver  HIV/AIDS Waiver  Mechanical Ventilator Waiver  Dual Eligible Program (HCBS portion only)

Home Again Timeframe

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365 days Home Again Program Waiver Services Transition Pre-Planning

Transition Coordination

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

Definition Transition coordinator is responsible for providing service counseling and assisting participants in coping with changing needs. The transition coordinator will also assist the participant with decisions regarding a successful transition into the community. The transition coordinator will also ensure continued access to appropriate and available services for participants.

Transition Coordination Qualification

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 Qualifications

• Bachelor’s degree in Human Services
• 2 years case management experiences with at least one of the program

target populations

Transition Coordination Service

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

Visitation Schedule

• During the first two (2) months, there must be two (2) face-to-face visits

and two (2) telephone calls per month.

• During months 3-12, the Providers will perform one (1) face-to-face visit

every other month and one (1) monthly telephone call.

Transition Coordination Service

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

Responsibilities (including but not limited to):

• Obtain informed consent from participant and/or his/her legal representative if

participant has been determined incompetent

• Assess participants medical, financial, and housing situation
• Develop a service plan for the participant
• Conduct Risk Assessment and Mitigation Plan
• Determine whether the participant is moving into a “qualified residence”
• Maintain a 24/7 backup plan for critical services (as is requirement to be a

provider)

• Conduct psychosocial assessments of the participant
• Evaluate Durable Medical Equipment (DME) needs of the participant
• Seek authorization from waiver case managers for waiver and Home Again

services that would be beneficial to the participant

• Provide individual health education training for the participant and caregivers

Transition Coordination Service

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

Responsibilities (including but not limited to):

• Conduct home visits of the participant
• Monitor transition and medical needs of the participant
• Facilitate transition meetings for the participant
• Explain to the participant the types of community long term services and

supports

• Assist the participant with housing needs
• Build and maintain good working relationships with waiver staff, Nursing Home

&ICF/ID, and PRTF staff, service providers, clients and caregivers

• Keep Quality Assurance personnel closely updated on transition activities on a

monthly basis

• Complete Transition and Discharge Checklists for participant
• Any additional work required by waiver and Home Again staff

Expanded Goods and Services

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

Participants are eligible for all waiver services including environmental modifications as part of the CLTC waiver.



Expanded Goods and Services may cover items such as:

• Furniture
• Appliances
• Initial Groceries
• Security Deposits
• Household items
• DME deemed necessary and not covered by either Medicare or Medicaid DME

Housing

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 Qualified Residences  Partnerships  Bridge Rental Subsidy  Challenges  Resources

To Make Each Case Successful…

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 Family Support  Advocate Support  Customer Education

Home Again Success Story

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https://msp.scdhhs.gov/homeagain/sites/defa ult/files/HomeAgainSuccessStory.mp4

Questions

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HomeAgain@scdhhs.gov

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