A House in Order: a Planning Guide Summary: This Is a Planning Document Developed by The

Dear George,

The 7th CMS New Freedom Initiative Conference was held March 5-7th in Baltimore. Presentations are available in both PDF and text formats. “Choice and Independence” is a key pillar of CMS’ vision for a person-centered long term services and supports system for the future. The 2007 conference focused on the policies, programs, and tools -including opportunities authorized by the Deficit Reduction Act– available to shape and carry out the vision.

2007 CMS New Freedom Initiative Conference: Access to Community Living: Promoting Independence and Choice Topic(s): Aging Issues, Children and Family Services, Consumer Direction, Deficit Reduction Act, Developmental/Psychiatric Disabilities, Employment, Financing HCBS, Housing, Long- Term Care, Mental Health, Money Follows the Person, Physical Disabilities, Quality, Resource Center, Single Point of Entry/No Wrong Door, State/Agency Information, Transition/Diversion from Institutions, Waiver Source: CMS

More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1869

A House in Order: A Planning Guide Summary: This is a planning document developed by the Ozaukee County Aging Services Department that helps individuals gather thoughts and discuss them with their family by asking, What Do You Want? This document, subtitled “Your Personal Guide for Planning a Happy Healthy & Independent Long Life” helps individuals take an inventory of the values and preferences. The guide recommends recording what you want and reviewing the list periodically with those closest so they can carry out the plans.

Topic(s): Aging Issues, Consumer Direction, Housing, Long-Term Care Source: Grantee produced, Wisconsin

A Report of Focus Groups and Personal Interviews Conducted in North Dakota’s Eight Human Services Regions Summary: Interviews were conducted to identify current perceptions, patterns, themes, and suggestions for improving the choice and self-direction, quality and access to long term care supports. This research also identified ways to develop a mechanism to balance state resources for services, and to identify elements for the design and structure of a single point of entry mechanism. Groups included: consumers of HCBS, elderly and younger nursing home residents, family members of consumers, and providers.

Topic(s): Aging Issues, Developmental/Psychiatric Disabilities, Long-Term Care, Physical Disabilities, Single Point of Entry/No Wrong Door Source: Grantee produced, North Dakota

A Report of Questionnaires Administered to North Dakota Hospital Discharge Planners Summary: This report describes the hospital discharge planner (HDP) survey conducted in the beginning of 2006. The HDP questionnaires were disseminated to gather information about the awareness of choice and access to continuum of care services for the elderly and people with disabilities as well as to gather ideas about how to optimize choice and improve access to these services. Review the results and read about the barriers faced by discharge planners.

Topic(s): Aging Issues, Developmental/Psychiatric Disabilities, Long-Term Care, Physical Disabilities, Transition/Diversion from Institutions Source: Grantee produced, North Dakota

More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1874 A Survey of North Dakota Consumers of Continuum of Care Services Summary: This report summarizes the research findings of a 2006 questionnaire disseminated to gather information about choice and access to continuum of care services. The survey gained information from consumers regarding services they are using, services needed, and barriers encountered. Data was gathered regarding how consumers learn about available services and suggestions to guide the development of a single point of entry (SPE) system, also called an Aging and Disability Resource Center (ADRC).

Topic(s): Aging Issues, Developmental/Psychiatric Disabilities, Physical Disabilities, Resource Center, Single Point of Entry/No Wrong Door Source: Grantee produced, North Dakota

Assessing Utah's Long-term Care System Summary: These reports are reviews of Utah’s long–term care system and waiver programs and provide recommendations for change. The Focus Group Findings focused on non- institutionalized and community based settings. The Long-Term Care paper provides more generalized findings about the structure of Utah’s long-term care system and how to transition forward based on input from stakeholders and administrators, comparisons to other states, and review of current documents and policy.

Topic(s): Aging Issues, Developmental/Psychiatric Disabilities, Financing HCBS, Long-Term Care, Physical Disabilities, Single Point of Entry/No Wrong Door Source: Grantee produced, Utah

Critical Incident Reporting and Recommendations Summary: One objective of the Texas’s QA/QI grant was to develop a uniform and automated critical incident reporting process. Information was collected on critical incidents reported most often by other states to be used with the Quality Assurance and Improvement (QAI) Data Mart. The QA/QI task force reviewed and used this information to develop a list of critical incident definitions and recommendations. Topic(s): Quality, State/Agency Information Source: Grantee produced, Texas

Demonstration to Maintain Independence and Employment: 2006 Solicitation Summary: CMS solicited proposals for this demonstration, created by section 204 of the Ticket to Work and Work Incentives Improvement Act of 1999. It allows states to provide benefits, equivalent to those provided by Medicaid, to the categorically needy, to workers who have physical or mental impairments that, without medical assistance, will likely result in disability. The Demonstration period runs July 2006-June 2009. This prior solicitation acts as a resource for terms, conditions and guidance.

Topic(s): Developmental/Psychiatric Disabilities, Physical Disabilities, Workforce Source: CMS

Development of Methods and Training for Assessing Personal-Experience Outcomes: Request for Proposals Summary: This Request for Proposals (RFP) concerned the development of methods and training for assessing personal-experience outcomes for adults with developmental or physical disabilities and frail elders. The grant awardee would contract to develop a tool and related tasks to assess person-experience outcomes and quality of life for the above listed populations.

Topic(s): Consumer Direction, Long-Term Care, Quality Source: Grantee produced, Wisconsin

Information Bulletins for ICF-MR Restructuring for Guardians of Individuals with Developmental Disabilities Currently Living in an Intermediate Care Facility or Nursing Home Summary: These six bulletins provide guardians with answers to frequently asked questions about changes to law that created the ICF Restructuring initiative requiring that community plans be developed for residents of ICF-MRs and that these placements be reviewed by courts annually to determine the most integrated, least restrictive setting for people with developmental disabilities.

Topic(s): Developmental/Psychiatric Disabilities Source:

Measuring Quality Using Experience Surveys & Results Summary: The following two reports are the result of face-to-face and mailing surveys to evaluate user experiences. The face-to-face surveys were conducted with people who are 18 years of age and older who receive Medicaid waiver or Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR) Program Services. The Children/Family Surveys were mailed to families of children under 18 years of age who received services in programs operated by the Department in 2005.

Topic(s): Aging Issues, Children and Family Services, Developmental/Psychiatric Disabilities, Physical Disabilities, Quality Source: Grantee produced, Texas

Medicaid Infrastructure Grant Announcement 2007 Summary: CMS was soliciting proposals to develop the infrastructure to support competitive employment opportunities for people with disabilities. Funding is intended to facilitate enhancements to state Medicaid programs and services, to promote linkages between Medicaid and other employment-related service agencies, and to develop a comprehensive system of employment supports. The demonstration period runs Jan–Dec 2007. This prior solicitation acts as a resource for terms, conditions and guidance.

Topic(s): Developmental/Psychiatric Disabilities, Physical Disabilities, Workforce Source: CMS

More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1877 Minnesota’s Real Choice Systems Changes Grant Presentations: 2004 Summary: In September 2004, Minnesota’s Real Choice Systems Changes grantees presented at the Illinois 2004 Systems Change Seminar. Presentations covered the Minnesota’s Personal Assistance Care Program, QA/QI grant, ADRC grant, and its Senior Health Insurance Program. A variety of topics covered include quality assurance, stakeholder involvement and personal assisted services

Topic(s): Aging Issues, Children and Family Services, Consumer Direction, Developmental/Psychiatric Disabilities, Long-Term Care, Quality, Resource Center, Single Point of Entry/No Wrong Door Source: Grantee produced, Minnesota

Nursing Facility Transition and Diversion: Six-Part Training Module 1: An Overview of Transition & Diversion Programs Summary: Module 1 is an overview of transition and diversion in the long-term care system. After a brief introduction to nursing facility transition programs, the presentation dispels some myths about the outcomes of transition and diversion programs. In addition, Module 1 discusses different aspects of nursing home transition and the legislation and lawsuits that have affected this process. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1823

Module 2: Independent Living and Person-Centered Planning Summary: Module 2 is an overview of independent living and person-centered planning. It discusses the history and philosophy of independent living programs and definitions of person- centered planning. This module particularly emphasizes interacting and communicating with persons with disabilities. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1824

Module 3: Outreach Activities Summary: Module 3 discusses outreach activities in nursing facility transition and diversion. It reviews different methods of outreach and how they can be developed to be effective forms of marketing. In addition, information for outreach contacts and resources is provided. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1825 Module 4: Nuts and Bolts of Transition Summary: Module 4 presents the basic components of a successful transition. Again, person- centered planning is a main component of the transition and helps set the goals for the process, as well as an accurate way to gauge its success. In addition, this module discusses the need for housing, financial management, and transportation in a successful transition. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1826

Module 5: Transition, Follow-up, Tools and Resources Summary: Module 5 guides service providers through the transition periods and its follow-up. Handouts include transition planning guidelines and timelines, nursing facility transition services, and expenditure reports. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1828

Module 6 & Appendix: Organizational Impact and Collaboration Summary: Module 6, the final module in this series, is an overview of organizational impact and collaboration in nursing facility transition. This section provides information on how developing nursing facility transition capacity may impact an organization and team. It also provides information on “bringing all the resources” together. The Appendix is also included. More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1831

Topic(s): Long-Term Care, Transition/Diversion from Institutions Source: Grantee produced, Michigan

Ohio Access Success Project Summary: Various informative documents about the Ohio Access Success Project, a grant sponsored project aimed at nursing facility transition. documents include a presentation and fact sheet for consumer on the program and a fact sheets about frequently asked questions on nursing homes.

Topic(s): Consumer Direction, Developmental/Psychiatric Disabilities, Physical Disabilities, Transition/Diversion from Institutions Source: Grantee produced, Ohio

More Info: http://www.hcbs.org/moreInfo.php/nb/doc/1846 Our Stories Project Summary: Completed over an 18 month period in 2004-2005, this project was conceived of as an activity that met the objectives of the Maine Real Choice Systems Change grant and the mission of the Maine Personal Assistance Services Association to build recognition and opportunity for the direct care, direct support, and personal assistance workforce through education, public awareness and professional development. Each story evolves out of a series of in-depth interviews and is told in the worker’s voice.

Topic(s): Consumer Direction, Long-Term Care, Physical Disabilities, Workforce Source: Grantee produced, Maine

Quality Assurance and Improvement: DataMart Software Requirement Specifications and Reports Summary: The goal of the QAI Datamart is to develop a consumer-based reporting and data analysis database using the Home and Community-Based Services Quality Framework. The QAI DataMart will support data analysis and decision support for quality assurance and improvement. The purpose of this Software Requirements Specification (SRS) is to document the customer’s requirements for the applications being developed or enhanced. The reports and queries available from the DataMart are also included.

Topic(s): Aging Issues, Consumer Direction, Developmental/Psychiatric Disabilities, Quality Source: Grantee produced, Texas

Real Choice Marketing Campaign Awareness Study Summary: These three presentations provide information about the Utah Real Choice marketing and awareness efforts. The “UCare” program was established as part of the grant and the surveys were conducted in 2004, 2005 and 2006. Using telephone surveys, survey participants were asked about their awareness and understanding of the UCare program before and after the marketing campaign.

Topic(s): Long-Term Care Source: Grantee produced, Utah

Texas QA/QI Survey Results and Presentations Summary: Presentations included information about the Quality Assurance/Quality Improvement (QA/QI) grant as well as the activities of the grant. Presentations were made on the results of the Measuring Quality Using Experience Surveys report. A presentation to the department’s management team on the Data Mart(s) is also included.

Topic(s): Quality Source: Grantee produced, Texas

The Caregiver Guide Summary: The Utah Real Choice grant produced “The Caregiver Guide” and they have shared several modules. Topics covered include: Community Supports to Stay at Home, Caring for a family member with mental illness, Hiring and managing personal assistants, Assistive technology, Creating an accessible home, and Caring for a child with special needs. Modules are also available in Spanish.

Topic(s): Accessibility, Aging Issues, Children and Family Services, Consumer Direction, Developmental/Psychiatric Disabilities, Long-Term Care, Mental Health, Olmstead, Physical Disabilities Source: Grantee produced, Utah

Washington's DDD Assessment Business Requirements Summary: This document, in several sections, describes the requirements for the new assessment system in Washington. The purpose is to provide a comprehensive assessment process that identifies the support needs of program participants, fairly and equitably provides a service level to meet their assessed support needs and provides for an individual support plan. This process incorporates the State's existing assessment and calculations for the Medicaid waiver. Topic(s): Developmental/Psychiatric Disabilities Source: Grantee produced, Washington

When CPIGs Fly- Meaningful Consumer Involvement in Systems Change Summary: Massachusetts was among the first states to receive a Real Choice grant and like many states, took a while to start the grant activities. The work of this collaboration did not always progress smoothly. Many setbacks were experienced by all parties. However, as the end of the grant drew near, key stakeholders looked back and realized that significant progress had been made. This report and a companion video documents lessons learned for policy makers and other stakeholders.

Topic(s): Accessibility, Consumer Direction, Sustainability Source: Grantee produced, Massachusetts

Worksheets and Transition Planning Forms: Ohio Access Success Project Summary: The Ohio Access Success project has shared various forms associated with their project aimed at nursing facility transition. The forms aid the planning and implementation of the transition process. Forms include Consumer Assessment, Referral Form, Relocation Plan and a Role Matrix.

Topic(s): Consumer Direction, Developmental/Psychiatric Disabilities, Long-Term Care, Transition/Diversion from Institutions Source: Grantee produced, Ohio

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