ࡱ> 9;8M #bjbj== 2WW%l"""8Zn?"$ JJJJ.JJdJV@ HS'":: $0?FT *JSystems Change Grants for Community Living Michigan Department of Community Health Proposal Abstracts Michigans Real Choice Systems Change Grant The overall goal of this project is to make enduring systems changes within Michigans community-based services so that individuals receive better care, resulting in greater quality of life. The project has three major components: the Long Term Care Outcomes and Evaluation System Initiative, the Virtual Organization Initiative, and the Consumer Cooperative Initiative. These components are related by the common themes of improved access, consumer control, quality services, quality of life and cost-effectiveness. The benefits of these initiatives will broadly impact individuals of all ages, in each of Michigans three waivers, and throughout long-term care services. The LTC Outcomes and Evaluation System Initiative seeks to strengthen our quality assurance and quality improvement system by expanding the roles of consumers and family members in system design, implementation and evaluation; by developing outcomes and quality indicators for the continuum of services from primary/acute care to home and community-based services to nursing facilities; by developing effective methods for assessing consumer satisfaction and quality of life; and by supporting quality improvement initiatives in local agencies. The Virtual Organization Initiative will develop a model for administering an integrated system of long term care, in which access and service delivery are coordinated across primary/acute care, home and community-based services and nursing facilities. The virtual organization is a business model that (1) allows consumers to use telephone or web technology to identify and arrange services, and communicate needs and satisfaction with services, and (2) allows providers to electronically link into a full service network to better serve customers. It is an opportunity to use the powerful, new e-business technology, combined with assistive technology, to empower consumers and realize greater efficiencies within the system. The Consumer Cooperative Initiative will develop a model in which consumers and family members will collectively assume responsibility for their outcomes and take control of the resources needed to achieve them. The Co-op will allow members to design and obtain the services they prefer, with more creativity, responsiveness and cost-effectiveness. This model offers an exciting advancement in systems changes in support of consumer-directed services. The LTC Outcomes and Evaluation System Initiative and the Virtual Organization Initiative will be conducted within Michigans LTC system, which serves the frail elderly, adults with disabilities (not served in the mental health system), individuals with dementia and individuals at the end of life. The Consumer Cooperative will serve children and adults with developmental disabilities or mental illness/emotional impairments. The Michigan Department of Community Health requested $3,478,800 and was awarded $2,000,000. Community-Integrated Personal Assistance Services and Supports (PASS) Grant Although in recent years Michigan has aggressively improved the quality of and expanded its publicly funded personal assistance services and supports (PASS), the service system for people with functional limitations will have to undergo infrastructure reform if it is to meet future challenges. Presently in Michigan, there are five discrete programs that offer PASS and serve over 73,000 children and adults. Each program was developed at different points in time in response to different needs, and has its own eligibility criteria, care planning protocols, assessment tools, information system, and varying degrees of consumer control. This 3-year project builds on existing system strengths to achieve radical systems change that will optimize community integration and quality of life for children and adults in Michigan by offering maximum consumer control of PASS in all programs. Project activities include a service delivery system analysis to clearly identify system-level needs which involves all stakeholders, including consumers and families; a cost analysis to identify possible changes while maintaining cost neutrality; training and technical assistance to consumers, personal assistants and caregivers, and agency staff; developing comparable care planning protocols and assessment tools; coordinating information systems; supporting a sustainable long term care work force; and establishing a feedback mechanisms for quality assurance for PASS in all programs. A Consumer Task Force will ensure consumer involvement in the implementation of all project activities. In addition to the integration of systems changes into on-going program development, Sustainability Summits involving all stakeholders will convene in Years 2 and 3 to develop a plan to ensure that each project activity is sustained beyond the grant period. Evaluation strategies using an empowerment evaluation model will be implemented throughout the project to ensure that formative and summative data results will inform ongoing project activities. Michigan requested $839,969 and received $755,972. Nursing Facilities Transition Initiative The Nursing Facilities Transition Initiative proposal will receive $770,000 ($1,2000,000 requested) over a three year period to develop a model to ensure that individuals with long term care needs will have opportunities to return to and/ or have access to supports and the capacity to remain in their homes and communities as long as possible. There are four basic components to intended activity as well as an intent to link with the other CMS grant activities and enhance the work of the Innovations Award grantee for housing (Corporation for Supportive Housing- CSH). Transition Activities will be designed to educate housing consortia & development activities in communities about the nature of needs and the strategies possible to meet the needs of individuals requiring complex care in community housing. Linkage with the supportive housing communities already engaged in creating newly available housing for persons with special needs will be the primary targets. There are at least 11 such consortia already in existence throughout Michigan. In addition, training, technical assistance and pre-development resources will come thru CSH to actually create housing. The Innovations award expects at least 150 units of housing to be available after 3 yrs of efforts. Additionally, 40 newly awarded Project Access Section 8 housing subsidies are to be linked with this grant activity. Contractual personnel will coordinate with the personnel of other components, individuals referred from Nursing Homes or deferred from nursing homes upon hospital discharge or diverted from other institution settings. A last-resort Transition Fund will help defray moving costs for extremely indigent individuals. Diversion Two such efforts will be piloted. One will be a funded social worker placed at the U/M Turner Geriatric Program to work with hospital personnel and link with local and NHT Initiative resources to assist individuals to return to or to find an alternative home in the community, thereby diverting a precipitous nursing home referral. The second such effort will be a similar function funded by MSHDA working to 1) assist existing residents of MSHDA-financed housing to age in place; and 2) in coordination with their human service partners, work to fill vacancies in existing MSHDA-financed housing. Education The educational component will provide education, training and technical assistance on specific aspects of the initiative to community collaboratives, to health care professionals, across the components of the initiative and potentially upon request from the public. Evaluation The evaluation component seeks to develop a prototype for evaluating the collective effort and incorporates a focus on 1) cost/ benefit analysis; 2) changes in quality of life; and 3) capturing the methodology and lessons learned. 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