Many seniors want to live independently in their home for as long as possible. When caring for a senior becomes too much for the caregiver, the senior is usually placed in a nursing home. According to Fox-Grage, Houser, Ujvari (2013), The typical cost for Home and Community Based Services is about one-third the cost of institutional care. However, 64 percent of Medicaid LTSS dollars for older people and adults with physical disabilities went to nursing facility care, even though most people prefer to live at home. Education is needed to caregivers, seniors, and the community about certain Medicaid funded programs to help seniors live in the community opposed to being placed in a nursing home. The Nursing Home Transition Program (NHT) is a service through Delaware County Office of Services for the Aging (COSA). COSA is the Department of County Government responsible for planning, coordinating and administering programs and services for the seniors in Delaware County, Pa. (www.delcosa.org). The NHT program assist individuals age sixty and over with moving out of a nursing facility. The program helps with eliminating barriers, so that individuals receive services and supports in settings of their choice. The Assessment Unit Director is responsible for running the NHT program and the Assessment Unit at COSA. However, each county in the state runs the program differently. The program is managed as followed. The program has one supervisor and one coordinator which limits the amount of transitions. The NHT Supervisor is also the Assessment Supervisor. The supervisor oversee all activities, monitor billing reports, networks with nursing home Social Workers, review referrals, and supports and educates the NHT Coordinator. The Supervisor reports to the Assessment unit Director. However, changes in rules or policy are implemented from the Office of Long Term Living. If the consumer requires special nursing home transition CRITICAL ANALYSIS REPORT 3
funding, a request must be sent to the Office of Long Term Living. The NHT program is funded by the Center for Medicaid and Medicare Services. If a resident living in the nursing facility wants to leave the nursing facility, but cannot without community supports. A referral is made to COSAs NHT unit. Depending on the residents medical and financial status, they will be connected to certain programs to help them live independently in the community. The NHT Coordinators or counselor's first step is to assess the resident's long-term support needs. During the assessment, the counselor reviews the resident's chart and pre-admission screening report, interviews nursing home staff. The counselor will give the resident a business card, and, interview the person's family or informal supports. The Nursing Home Transition Counselor will call or visit the consumer twenty four to forty eight hours after discharge. Then a three, six, and twelve month call or visit is required. If I was COSAs director, I would not change much about the NHT program. I think the flow process for the NHT program is very effective. However, I would change the Agency Organizational Chart. I would not have the NHT program under the Assessment unit. The NHT program will function independently. By doing this, the director of the NHT program would focus strictly on the administrative task such as, billable reports, updating policies and procedures, and networking with the Office of Long Term living. This NHT Supervisor would be able focus on supervising the NHT Coordinator. The NHT Director and NHT Supervisor could focus more on promoting the NHT program and increase the amount of residents transitioning out of the nursing facilities. If I was COSAs director I would hire an additional NHT coordinator. By bringing on additional staff, I could increase the amount of revenue the agency receives. This could double the funding. Funding for the programs is available from the Center for Medicaid and Medicare CRITICAL ANALYSIS REPORT 4
services. COSA receives money for each transition completed, and each three, six, and twelve month follow up completed. The more transitions completed, the more money COSA receives. I would look for staff or interns that are self-sufficient, friendly and provides excellent customer service skills, caring towards other, and have a history of helping others. It is important to care for the people you serve. Empathy is needed to show compassion. Many seniors dream of living independently. They are searching for a feeling of safety and security. They want a NHT Coordinator, who will solve the problems that they cannot solve independently. According to The Gerontologist (2007), research shows that prominence of individuals who were discharged from a nursing home through Nursing Home Transition remained living in the community for one year or more.
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Reference (2014). Information retrieved June 30, 2014, from www.delcosa.org. Houser, a, Fox-Grage, W, Ujvari, K. (2012). Across the States 2012: Profiles of Long-Term Services. Retrieved from http://www.hcbs.org/files/218/10855/across-the-states-2012-brief.pdf Howell, S., Silberberg, M., Quinn, W., Lucas, J., (2007). Determinants of Remaining in the Community After Discharge: Results From New Jersey's Nursing Home Transition Program. The Gerontologist Vol. 47, No. 4, 535-547.