[Job 9121721]
Learn & Share - Nursing Home? No, Thanks! First Conversations for Community-Based Transition Services
Event Name: BIS-APUI-9121721
June 25, 2025

CONFIDENTIAL ROUGHLY EDITED REALTIME FILE
Compliments of Birnbaum Interpreting Services

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This file was created in real time by a Realtime Captioner. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings. A consumer should check with the presenter for any clarification of the presentation.

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>> Good afternoon, everyone!  I want to take a few seconds to let people in from the waiting room before we get started. I think we are right at a good spot to go ahead and kick off for, first of all, welcome to the independent living training and technical assistance centers, learn and share series. 
	The IL, T&TA center is available through a contract with the United States Department of health and human services and operated out of the University of Montana's Rural Institute for inclusive communities. My name is Bethany Baldwin and I am the IL coordinator at the national council on independent living, working on behalf of this project. We are so excited to be kicking off today's topic, centering on community based nursing home transition services. Today's session was titled, nursing home, no thanks!  First conversation for community‑based transition services. Next slide. Before with we get started, we always like to go over housekeeping accessibility notes. 
	First off, ASL and Spanish interpreters are available and labeled on the screen. They will be spotlighted but you can pin the interpreter in your individual settings or access via the interpretation channel. You can access closed captioning by clicking the CC button located on the bottom of the Zoom window. We can access the CART via the link provided in the chat. As always, we hope to have an active peer sharing portion after the presentation. That means please use the Zoom raised hand or chat features to ask questions and once you do, come on, we would ask that you state your name and your organization before speaking, while the presentation is going, please take a note to stay on mute when you're not talking. 
	Throughout the presentation, you can message our chat feature if you have any difficulties with today's call. We will be using the chat throughout the call, for links and resources and whatnot. If there are any questions, we will be sure to verbalize any of them and also comments in the chat. And finally, at the end, there's a survey and we would love to get your feedback during this presentation and next slide. All right. So here is what to expect today. In terms of the nursing home transition, we have some finding of the regulations used and we will also follow up with practice and action with a focus on our presenter's from center on disability rights. They will be showcasing a quick walk through of what an effective nursing home transition within the skilled set up looks like. Then we will move into the peer discussion of the flexible learning and share format which spotlights the content first and then segues into open discussion and allows for all to participate in whatever feels right, whether it be voice, chat, or video. Next slide. 
	
	The key take away we're looking to achieve with this sharing is three of them. First off, starting the conversation strong. Where do I begin?  Coaching staff will ask insightful questions to initiate meaningful discussions about consumer goals and current circumstances. Thus laying the foundation for consumer driven transition. Second is challenging bias and supporting consumer led decisions. Are they ready?  Guiding staff to address internal bias while making sure that the decision is consumer. The third is strategizing for success. Is this achievable?  Helping staff translate broad consumer goals to project, achievable milestones that pave the way for a successful return to community and the consumer independence. But as always, we hope to have the overall goal of this learn and share is to learn with and from each other. Next slide. 
	I am so excited to welcome our two very strong voices from the center of disability rights located in Connecticut. First off, we have Rick who is the senior advocate there. And then there's Tim Parks who is the program manager for money follows the person and at this point, I am going to hand it over to them. 
	
>> This is Mary Kate, Rick, and Tim, you're muted. 
>> Thank you, I think I just fixed it. Good evening, everybody and thank you for attending our little training on the nursing home transition. My name is Rick and I am the senior advocate here at the center of disability rights and previously, I was at nursing facility transition coordinator supervisor here until Tim took over that position. I have a spinal cord injury, C6, C7, incomplete quadriplegic and I have been working for the center for five years. 
	
>> Hi, my name is Tim and I'm a supervisor here at the center of disability rights. I'm sorry, and I have been here for just over 15 years and I have been working on money follows the person and I am someone with a hearing impairment. I should say I'm deaf and I wear a cochlear implant to help me with my hearing. Next slide. 
	
>> About center for disabilities CDR. We are located in Connecticut and we employ 12 staff, 6 of which are dedicated to money follows the person which is subcontracted by the Department of social services. We have four transition coordinators which are the driving force of the transition and we have two housing coordinators which can it's their job to be solely dedicated for finding help and getting consumers to secure their housing. We live in a county which totals of 35 cities and towns in Connecticut and we're an advocacy organization. 
	It exceeds our quarterly requirements for transitions each year and each quarter year, averages and expects to discharge 10 to 15 consumers out of nursing homes per year. Next slide. 
	Program performance report PPR expectations for reporting core transition services. Centers for independent living, CILs must report all transition activities as a core service including consumer transactions ‑‑ I'm sorry, transitions out of institutions would be today's focus and youth to post secondary life. So youth to post secondary life would be something like higher education, maybe moving from school to a job and those things and transitioning out of institutions would be, nursing facilities, rehab facilities, residential care facilities. 
	Nursing home transition services definition, under the Rehabilitation Act, E. Independent living core services, section 5, services that one, facilitate the transition of individuals with significant disabilities from nursing homes and other institutions to home and community‑based residences with the appropriate support and services. This process may include providing services and supports that the consumer identifies are needed to move that person from an institutional setting to a community based setting including systems advocacy required for the individual to move to a home of his or her choosing. Next slide. 
	
	Nursing home facility transition service transition under the Rehabilitation Act continue. Two, to provide assistance to individuals with significant disabilities who are at risk of entering institutions so that the individuals may remain in the community. A determination of who is at risk of entering an institution should include a self‑identification, by the individual as part of their intake or goal setting process. Defined within the relocation act of 1973 as amended in section 29USC75, 17, section E five, 1‑2. 
	Center for independent living performance report, PPR part two instructions. Subpart III individual services and achievements. Section 725 c 8 c of the act, section B independence and community integration. Item one, XWOELs related to independent and significant life area. Relocation from a nursing home or institution goals related to relocation from nursing homes or other institutions to community based living arrangements. The significant life area specifically pertains to consumers who live in a home run institution unlike a community based which includes any consumer regardless of his or her living situation prior to receiving IO services. Next slide. 
>> Hi, Rick, this is Bethany. We just received a chat to see if you guys can pull the camera down just a little bit so we can see more of your glorious face. There you go!  Perfect!  
>> Thank you, sorry, I dance around a lot and I can't sit still. Sorry, okay. The goal reporting of nursing home transition with the PPR, the purpose is to capture consumer outcomes tied to independent living services. Quantify progress in significant life areas like housing transportation and housing access. Report activities under the core services, nursing home transition. Next slide. 
	The goal of reporting nursing home transitions in the PPR continues. What matters?  Demonstrates the impact of IL services on real lives. Shows how nursing home transition supports community integration, not just the discharge. Meets federal expectations under 29USC705 section 17E5. And the only measure tracked in the congressional budget justification. Expected outcome and increase of the succession of people, successfully relocated from institutions to community based living by CILs and based on goals set by set, versus goals achieved.  
	What must be reported in the PPR for nursing home transition?  Is the total number of consumers assisted with transitioning from institutions to community based living. And recorded transitions still in progress as an example of goals in progress. Including a number of consumers served, number of goals created or achieved or in progress and consumer stories or examples used for impact. Next slide. 
	What must be reported for the PPR for the nursing home transition continued?  Is best practices on using the real location from a nursing home or institution on the PPR. Only use this category for institutions to community transitions. Do not combine with community based living which helps prevent under reporting, nursing home transition work. Next slide. 
	
>> Hi, my name is Tim and what does doing this mean?  Why nursing home transition matters. We help people with disabilities who are our peers transition out of institutions such as nursing homes, hospitals, rehabilitation centers, mental health facilities, group homes and other congregate settings to return to homes in the community. People with disabilities have the right to decide what supports they need, we listen and follow their lead. The goal for people with disabilities is choice, freedom and control of your lives. It's about the consumer choice and the consumer is always the driver of the process. Our role is to assist and remove barriers and not just providing services. Next slide. 
	Centering independent living in nurses home transitions. This is overall center, shifting away from the medical model and ensuring consumer control in the process. Advocate for consumer directed planning. Encouraging IL values, self‑direction, peer support, consumer control. Collaborate with other centers for independent living, now and keep in mind, a lot of times, there could be others for independent living that might be involved that could be because the consumer that we might be working with, and our catchment area may be going to another area of the state. It's important to review with the consumer and to involve them with the other center for independent living because they might be able to obtain their services and to help them facilitate the transition from them from a nursing home back to their home. 
	Building trust from the first contact. Meet the consumer first before interacting with the facilities staff. An example would be really the first contact meeting, you should be trying to get to know the consumer, how they ended up in the nursing home or in the hospital and really, just knowing what their life was before, prior to their absence or ending up in the nursing home. 
	The first meeting should be on the consumer's term and their schedule, what works for them. Maybe the mornings don't work for them. Oftentimes I can say for myself, I meet with the consumers in the afternoon because a lot of times their care they need from their aids in the nursing home or hospital, they end up being done in the mornings so it's a good time to meet with them in the afternoon. 
	Build a rapport with the consumer. Encourage the consumer to lead the conversation. Be practical and transparent with the process. Explore the why behind the work. Why are we doing this work?  We are there to help that consumer to be in the community and live their life again and not be in the nursing home. Lastly, emphasize peer connection. If I can, you can. Next slide. The. 
	
	Getting the whole story and understanding the journey. Gathering the background thoroughly, ask open ended questions, try to stray from yes or no questions. What brought you here?  What matters to you?  What do you need to live in your home and in the community?  So this is also a part of, you can build your trust with the consumer with these questions. The consumers know how they got there. Maybe they had this disability for a while. Maybe it's the first time in a nursing facility. Maybe it's the second or third. We gather the story, how did you get here. What fell apart that brought you here?  Did you lose your PCA?  Did you lose your eligibility for services?  What do we need to do to so those things do not happen again. 
	Am I ready?  Challenging barriers and a consumer's right to take risks. So we have internal barriers and influences that can get in the way of transitioning your consumer. Believe it or not, even CIL get. Nursing facilities, social workers, sometimes administration, case coordinators from be home and healthcare agencies can also be problematic. 
	I ran into a home care agency where I would discharge a woman and she lived on the second floor and the concern was, what if there's a fire?  My response to that is, where is your bedroom in your house?  On the second floor. Do you have another way to get out of your bedroom other than that one staircase?  No. Well, if there's a fire in the bottom of your staircase and you're burning you and you don't have a disability. So what's your problem?  
	Affordable and accessible housing. That can also be a problem. How many times does a landlord, when you're looking for housing with a disability, oh God, what is the liability if I rent here and they get hurt?  Timelines and deadlines. Get those applications in on time otherwise you'll be late and someone is not found eligible and they will miss out. Including housing. 
	Family support and opposition. Sometimes families are against the transition. A lot of times they're concerned with how the person is going to be taken care of in the community and sometimes that's a legitimate concern. And sometimes families are just fed up and don't have the time to help. 
	Conservatorship and guardianship. The same thing added. The conservatorship can be a court appointed attorney and don't have as much time to give attention to the consumer and that can be problematic. 
	Consumer barriers, yes. They can have their own self‑doubts, fears and fallacy of independence thinking that if I ask for too much help, I'm never going to leave here. And if I only ask for a little bit of help, I'm going to get out of here faster. Next slide, please. 
	
>> Make it theirs, shared planning and responsibility. Who will do what?  Clarify transition team and consumer's role. Who is going to take what lead in how are the steps going to be completed?  Develop the independent living plan. ILP through informed consumer choice. What goals do the consumer want to achieve to get back to his or her community or home?  Build a consumer controlled circle of support. That can be a variety of partners that might be involved in the transition process. It could be the family or friends of the consumer, the medical team, the social worker, they are all a part to provide that transition for the consumer to go back to the community. 
	Empower the consumers to be involved to the extent of their ability. It's their transition and their life, next slide. Make it their key ‑‑ key components of nursing home transition support. Communication is a team effort. It's essential that everyone communicates their role and the steps that need to be done because without communication, their transition will not move accordingly. Independent living skills, eligibility for self‑directed care, budgeting and benefits navigation, medication and supply coordination, transportation, planning. Budgeting and navigation is very important because the consumer really needs to know when to pay their rent and allocate their income to be able to pay their bills and that's something that we strive to always work with our consumer to make sure it's done because if they don't pay their bills, especially their rent, that is on terms of, could possibly result in an ‑‑ making sure Medicaid is up to date and they're doing their redeterminations and that kind of stuff. 
	Medical, medication and supply coordination, we have to make sure when we do our discharge meeting prior to a consumer leaving the nursing home to go back to the community. Their medication is ordered and they are going home with the medication they need until they see their doctor. 
	Again, that doctor appointment can happen within a couple of weeks. They just need that medication up until that point. Transportation planning, review with the consumer. The options that are in the community to get around, especially to their medical appointments. 
	Secure, accessible and affordable housing. Accessibility and safety evaluations, durable medical equipment, DME, home modifications coordination, if we have a consumer going back to their home or to a new apartment, we will need a call home about that and it will determine what durable medical equipment they may need in the home but also, any kind of home modifications such as a ramp because the consumer, if they're using a wheelchair will need a way to get into their home. So it's essential that it be figured out prior to the consumer moving back to their home and then lastly, would be shopping support for special supplies, discharging them back to home and community. And we as transition coordinators work with the consumer on trying to get household items, furniture, items they will need in the home so that is something that we would do to try to make that, to ease that transition for that consumer. Next slide. 
>> Can I add something?  Can we go back to 21, please?  Thank you. I just want to add something about the budgeting and navigation. I play very close attention to this especially around income. You want that income and your benefits to be restored in the community at time of discharge or very close to it. Oftentimes, people do get denied services and your transition coordinator should know about the entitlements, front wards, backyards and sideways because we have done, or requested a lot of appeals for when people get denied services. And that goes into the advocacy part and teaching them if they were denied services. Next slide. 
	Okay, post‑transition quality of life follow ups. We need to ensure that the consumer is stable in the community. How it's done, from our centers standpoint under the MFP program, money follows the person, we extend and really are involved with the support, 365 days for the year. And we do our follow ups, when someone transitions, we follow up three days after transition, thirty dais after transition, 60 days after transition and 90 days after transition but it can be ongoing, up to the whole year. Really, the goal is to address any issues related to care, housing, or health. And we use FOL up to evaluate the quality of life and service needs. That can be what is working for the consumer, what is not working for it the consumer. 
	Is there a need being met?  If not, what can we do to help that consumer get their needs met?  Sometimes that could be that if there's an agency based personal care assistance, where they may not be providing the rights person to work with them. Maybe they are not showing up in that. Maybe it requires for someone else to work with them. So that would be an example for a follow up question that may need to be addressed for that consumer. 
	Additionally, core services are available as long as the consumer has active goals to support their transition and reintegration into the community. 
>> Real people, real shifts, peer stories of transition. 
	Mark, a 53 year old adult male returned to the community living on his terms. And this person was morbidly obese, probably like 600 pounds. So we need to make his apartment far more accessible than regular ADA standards. 
	We had to convince the landlord to allow us to make all the door ways minimal, 42 inches wide. Which is one of the challenges. Judy, a long term institution due to traumatic brain injury and her 8 year path to reclaimed independence. Judy was in a nursing facility and acquired her brain injury from an abusive relationship and she was in a nursing home. The nursing home was really against her going home. Probably because she was easy care. It took one of my directors to volunteer to become a conservator to complete it and it still took us 8 years to do it. Between fighting with the nursing home and getting the consumer ready and confident to make the move, it took that long. 
	Ryan, Ryan is a transition from ‑‑ I will never forget doing. He was a 16 year old kid and broke his neck riding on a BMX bicycle. I was introduced to him and at the time, it was not money follows the person and I had to wait until he was 18 to begin working with him. When he turned 18, he entered a facility and while he was in the facility, we advocated with the Bureau of rehabilitation services in Connecticut and he finished his high school education from the nursing home. He graduated in architecture certificate from a tech. Shortly after his discharge, we were able to get him a mini van so it was equipped for someone to transport him around and he's still living in the community today. I still him every once in a while on Facebook writing poetry. 
	Not all transitions are successful. At the going of this presentation, you read as to why we do this in terms of PPR. The reason I do this, I broke my neck in 1985 and in 2000, I started working for the center of disability rights. I was on the Olmsted community that got the first project established here in Connecticut and my director and my then supervisor Sandy Roberts, they took me to a nursing home to visit an individual and who had a spinal cord injury. 
	I am known at the center to not have feelings. I saw this guy in bed, wrapped up in blankets like he couldn't move and I couldn't hold back my tears. I left that facility swearing I would never go back to a nursing home ever again. Two years later, I started getting people out of nursing homes and that is the reason I do it. The only reason why I'm not in a nursing facility is because my parents owned a home and were able to modify it and I had a place to go. I believe that's it for me. Thank you!  
>> Additional guidance, these you can get online. This is the transitions out of institution, administration of community living:  Housing and resource center. Next, what is choose, get, keep, integrated community housing, ILRU and the IL‑NET. 
>> ABCs and nursing home transition and orientation manual for new transition facilitators, a great resource for those who are just coming into the field and are doing transition work. This would be a great opportunity to go online and look at this manual because it has a lot of good pain points for those who want to learn about nursing home transitions. 
	
>> Recording stopped.