Helping folks go back home

Posted: Wednesday, March 14, 2007

Mr. Jackson was transported from his village to a nursing home in a city, following a devastating stroke. The stroke left him unable to use his hands, unable to walk, and he had difficulty swallowing. But, more than anything, he wanted to return home to his traditional village. Fortunately, he was put in touch with Rita Walker, the Program Coordinator for Alaska's Nursing Facility Transition Program. Rita helps people who are in nursing homes to move back into their community and return home.

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In order to return home, however, Mr. Jackson needed services and supports available and in place to live safely. Such services were not already established in his village so, with Mr. Jackson's help, Rita identified a local resident who was willing to serve as a personal care attendant. The Program then paid for the person to travel to Anchorage for two days of training on how to care for Mr. Jackson, including meal preparation, feeding, toileting, bathing, dressing, and wheelchair transfers.

In addition to training persons to serve as paid caregivers, the NFT Program will also pay for home modifications such as grab bars or wheelchair ramps; trial trips to home; one-time funds for an in-home worker until Medicaid services are approved and in place; security deposits; initial cleaning of home; basic furnishings to set up a livable home; transportation and other items or services as approved by the program coordinator.

Rita is the only staff member in the NFT Program. She works closely with a care coordinator (there are many care coordinators throughout the state) to link the person with the services that he or she might need. The care coordinator screens people to see if they are medically and financially eligible for the Medicaid Home and Community Based Services Waiver program. If eligible, the Medicaid HCBS Waiver will pay for services once the person has made the transition back to their own home. Individuals interested in moving from a nursing home back to their own home should contact Rita (907) 269-5025 or their care coordinator (if they have one). Rita will set up a meeting with the person, their family member(s), and a care coordinator to develop a "transition plan." Once the care coordinator screens for eligibility, she asks the Division of Senior and Disabilities Services to conduct a comprehensive assessment of the person's functional level and impairments. The assessor will identify what needs and problems are present as well as the individual's current abilities and support system.

The care coordinator refines the "transition plan," incorporating the services that are needed to help the person live safely in his or her own home. The person chooses a date to move home and the care coordinator arranges for the coordinated delivery of those services within the specific time frame. "We can't transition them home until we know they'll have the services in place," explains Rita. For example, grab bars need to be installed, supplies need to be delivered, services need to be arranged before the patient returns home. Once everything is set up, the person moves back home.

"We have transitioned 156 people since I started this program four years ago," says Rita. "I love being able to give people something they need and really want - that independence and sense of control over their lives." Two major surveys have asked clients about their quality of life after the transition. "For most of them, their health improved. All of them said their quality of life is better at home."

• Marianne Mills is the program director of Southeast Senior Services, which offers home and community-based services for older Alaskans throughout the region. SESS is a part of Catholic Community Service and assists all persons regardless of their faith.

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