Nursing Home Transition and Diversion Services

 

"She wants him home and he wants to be there to be
the father to his children."
NHTD staff member describing the desire of a paralyzed father to live at home

 

Some people, because of the after-effects of a health crisis, a critical or chronic illness, or injury, are evaluated and determined to be medically eligible for admission to a nursing home. Often that isn't the individual's wish but there doesn't seem to be any alternative to the nursing home.

— OR —
after a period a period of time living in a nursing facility, a person with a disability wants to leave and re-locate with family or live independently in the community but can't assemble the home care services needed, training programs, the workers to make the home accessible, or afford or coordinate the move. There wasn't anyone to evaluate and access the needed help.

Now there is.

 


 

The New York Sate Department of Health has created a Medicaid services waiver (Home and Community Based Service Medicaid Waiver Program for Nursing Home Transition and Diversion for all adults with disabilities and seniors - NHTD) to address these dilemmas.

The waiver allows these individuals the choice of living in the least restrictive environment of their choice with support from family, friends and health and human service professionals.

The waiver recognizes:

  • the desires of the individual,
  • the basic human rights of all to be in control of their own lives, encounter and manage risks, and learn from those experiences, and
  • that, with the right supports and services, the person can live safely and thrive in some place other than a nursing home.

Access to the waiver is provided by service agencies who are trained to provide assistance in assessing needs and providing or accessing the required services for the safety and health of the individual and the cost effectiveness of the program.

The NYS Department of Health regional NHTD Waiver services center, the Regional Resource Development Center, must determine that the person has a disability and 18 years of age, has a evaluation, a Patient Review Instrument- PRI, that indicates nursing home eligibility, is able to live in the community in a safe and reasonable way and that the support services needed can be provided in a cost effective manner for the region and New York State.

Catholic Charities Community Services provides this Waiver service to people over 18 years of age with ANY DISABILITY. The agency is uniquely qualified to provide this service to persons with disabilities because of the over 30 years' experience the agency has working with people with various disabilities. (Other local service agencies provide this service to seniors.)

The agency will:

  • evaluate the level of services need to live safely outside of the nursing home environment,
  • provide or access those needed supports, and
  • identify what needs can be met by family and friends.

For information about services and programs, please contact Tracy McNett, NHTD Director or the contact listed for each service below.

SERVICES

Service Coordination

Key to the success of the NHTD Waiver services is a service coordinator who assists the individual with:

  • gathering the information needed to prove eligibility for the waiver services,
  • developing an individual service plan to needed services that might include skills training to develop personal independence, psychological counseling to address changes in lifestyle, supportive healthcare and food services, modifications to homes and adaptive equipment to adequately provide for any specialized needs of the client, and day program activities
  • securing a residence in the community that meets the individual's health and safety needs,
  • accessing additional services as needed, that might include home healthcare providers, transportation, home delivered meals.
  • reviewing and updating service plans as needed.

The relationship with a service coordinator is a professional one, and Catholic Charities Community Services staff members meld that professional attitude with a deeply felt desire to serve the individual in the best possible way. Contact: Karen Rowland, Service Coordination

Independent Living Skills Training

When eligibility for services is secured, NHTD Services trainers can assist with training in living skills, assessing, instructing and supervision in activities of daily living as needed and wanted that might include but are not limited to memory, organization and processing, money management, household tasks, self-help skills, community integration and other aspects of independent daily living.

Special training required of staff equips them with the knowledge to develop techniques for clients in gaining or re-gaining these skills while maintaining the individual's dignity. Contact: Kelly Finnigan, MSW

Community Integration Counseling

Establishing one's self in the community either with family or living independently can be difficult. To address this challenge, Catholic Charities Community Services can provide counseling for the individual and the family as they confront this re-entry into the community. Contact: Kelly Finnigan, MSW

Community Transitional Services

Community Transitional Services are made available for a one time move from a nursing home to a private home or apartment and may include funding for moving costs, essential furnishing, deposits for utilities and/or rent, or one-time cleaning.

Other Special Services Are Accessible

The service coordinator can also access service available through state funding sources and other agencies which include:

  • Assistive Technology
  • Environment Modifications
  • Home Delivered Meals
  • Home and Community Support Services
  • Nursing Visits
  • Medical Home Visits
  • Moving Assistance
  • Nutrition Counseling
  • Peer Mentoring
  • Positive Behavioral Interventions and Supports
  • Respiratory Therapy
  • Respite Care
  • Structured Day Program
  • Wellness Counseling

Funding

The Catholic Charities Community Services NHTD Services is funded through the NYS Department of Health Home and Community Based Service Medicaid Waiver Program for Adults and through general donations to the agency.