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Transitioning People from Institutions to the Community 105institutional services can be higher than thecosts of HCB waiver services furnished to personswho have not been institutionalized. Thiscost differential arises in part because manyinstitutionalized persons have multiple functionallimitations that require more intensiveservice provision to enable them to remain inthe community. But the main reason for highercosts is that such individuals tend to requiremore paid services simply because they frequentlylack adequate networks of informaland community supports (a lack that led totheir institutionalization in the first place).Although most states accommodate transitioningindividuals from institutional settingsthrough their existing HCBS waiver programs,a limited number operate distinctHCBS waiver programs for people transitioningfrom institutional settings. For example,Georgia created a special HCBS waiver programfor individuals who transitioned to thecommunity during the state’s closure of its320-bed, Atlanta-based Brook Run facility in1997. Closure of this facility resulted in costsavings that enabled Georgia to provide HCBwaiver services to 180 additional individualsover and above the persons placed from institutionalsettings.• Development of family support programs. Familysupport services are crucial in avoiding unnecessaryplacements and are used by manystates to reduce reliance on institutional services.For example, Michigan reduced the numberof individuals it served in large publicfacilities from over 6000 in 1977 to fewer than300 in 1998—in large part by launching andsustaining family support programs.• Development of strong, locally centered communityservice systems. In developmental disabilitiesservices, creating a strong infrastructure at thecommunity level has proven important inavoiding institutionalization and promotingquality service. Development of New Hampshire’slocality-based, non-profit Area Agencysystem played a major role in facilitating closureof its Laconia facility. An important stepin Michigan’s transition activities was thestate’s strengthening of its network of localgovernmental Community Mental Health ServicePrograms. As part of its overall plan toclose its Brandon facility, Vermont placedmajor emphasis on upgrading the skills of itscommunity workforce and maintains a strongprogram of training community workers. InKansas, the state developmental disabilitiesauthority and the state’s University AffiliatedProgram forged a partnership to improve thetraining and skills of the community workforce—astep that was instrumental in enablingthe state to transition many institutionalresidents to the community.• Making large-scale investments in quality assuranceand quality improvement capabilities. Wyomingused such an investment to successfullyplace more than two-thirds of all the residentsof its State Home and Training School in thecommunity during the 1990s. The Division ofDevelopmental Disabilities outstationed acadre of field staff—initiating a comprehensiveprogram of top-to-bottom reviews ofcommunity programs (including highlightingbest practices), among other steps to improveworker training.General Factors to ConsiderAlthough states have much less experience transitioningpeople out of nursing homes than out ofICFs/MR, the earlier experiences transitioningpersons with mental retardation and other developmentaldisabilities to the community providevaluable lessons for transitioning residents ofnursing homes; and the same principles apply.The ability to achieve successful transitions frominstitutional to community-based living dependsfundamentally on the ability to match the needs ofthe persons who have been living in nursinghomes or other institutional environments withthe availability of home and community servicesto meet those needs.Persons leaving ICFs/MR have varying types andlevels of need. Residents of nursing homes orother types of institutions are an even more heterogeneousgroup. In the same nursing home, forexample, the individuals to be transitioned may
106 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERNursing Home Transition Grants ProgramTo assist states in providing transition options toMedicaid beneficiaries residing in nursing homes,HHS—through the combined efforts of HCFA andASPE—has sponsored a grant program entitled the“Nursing Home Transition Program.” Its purpose isto assist current nursing home residents who chooseto do so to move to home and community settings,remain there safely, and maximize their participationin community life. In 1998, grants averaging $175,000were made to four states: Colorado, Michigan, RhodeIsland, and Texas. In 1999, grants averaging$500,000 were made to four additional states: NewJersey, New Hampshire, Vermont, and Wisconsin.Each of the grantee states has implemented transitionprograms unique to their long-term care systems.HHS plans to continue making grants underthis program for one additional year and perhapslonger. The 1999 Supreme Court decision in theOlmstead case, which requires states to developplans for serving persons with disabilities in the community,has increased state interest in the program.include a 75-year-old with cognitive impairmentand multiple medical problems, a 45-year-oldwith quadriplegia, and a 25-year-old with a traumaticbrain injury. They will have some needs incommon. But they will also require services andsupports tailored to their specific situations.Whether a person currently resides in a nursingfacility or an institutional facility the state is downsizingor closing, the steps in planning or arrangingfor community services are the same. In either casesolid transitional planning is essential. However,additional challenges are involved when downsizingor closing an institutional facility, includingmaintaining the quality of facility services andworker morale, assisting workers to find otheremployment, addressing the “dual funding” problem(i.e., meeting the costs of maintaining facilityoperations while underwriting the costs of communityplacement), and ensuring that any specialservices provided in the facility will be available toindividuals after they have left the institution.Because each person has unique needs, the complexityand cost of an individual’s actual transitionprocess will vary. For this reason, it is crucialthat transition programs be designed to operatewith maximum flexibility. However, seven overarchingsteps need to be taken in setting up alltransition programs, irrespective of the particularneeds being addressed:• Identifying and addressing administrative andlegal barriers• Identifying and educating residents with thedesire and the potential for transition• Involving and collaborating with key playersin the disability arena• Developing and implementing care managementsystems that support transition• Identifying and addressing housing needs andpayment sources• Providing innovative and flexible fundingmechanisms• Establishing a quality assurance system thateffectively balances risk and autonomy.The remainder of this chapter discusses theseactivities as they relate to the transition of nursinghome residents to the community. It is importantto note that, although Medicaid can be used tohelp support many of these activities, states thathave undertaken transition programs or facilityclosures emphasize that many costs associatedwith them are not covered by Medicaid. Suchcosts can include temporary rental assistance, furnitureand clothing, and direct cash payments toindividuals and families for one-time costs associatedwith the move.Identifying and Addressing Administrativeand Legal BarriersThe first step a state must take when consideringwhether to start a transition program is to analyzestate Medicaid regulations and administrativepolicies. This is to identify any institutional biasthat might make it difficult or impossible for somepeople living in nursing homes to be served in thecommunity. If a state does not use the 300 percentspecial income rule for its HCBS waiver program,for example, some nursing home residents will
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IntroductionPeople of all ages with
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Introduction 31998—is the group m
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Introduction 5This Primer has been
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CHAPTER 1Medicaid Coverage of Home
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Medicaid Coverage of Home and Commu
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Financial Eligibility Rules and Opt
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