Christine Duffy MFP Program Coordinator

Money Follows the Person (MFP) Demonstration Identification of and

Outreach to Nursing Home Residents Project

Providing Objective Information on home and community–based services

to Nursing Home ResidentsChristine Duffy

MFP Program Coordinator

St. Mary’s Healthcare System Money Follows the Person

New York State Department of

Health has contracted with

St. Mary’s Healthcare System as a

designated Local Contact Agency

(LCA) to implement the MFP project in

the New York City Region.

The purpose of MFP is to provide certain nursing home residents, identified by the Long Term Care Minimum Data Set (MDS), with

objective information on

home and community-based

services, that may be available

to them.

MFP staff then can provide additional

assistance with discharge

planning, as requested by the

resident, their families and/or the social work

staff of the nursing home.

WHAT IS MONEY FOLLOWS THE PERSON (MFP) DEMONSTRATION IDENTIFICATION OF AND OUTREACH TO NURSING HOME RESIDENTS PROJECT?

The DOH provides MFP staff with a list of nursing home residents who may be good candidates to transition back to the community

•Determination is made based on the

RUG score on the nursing home MDS.

Residents and / or their family can let the social worker or MFP staff know they would like to receive information on available community based services.

Social work staff at a nursing home may make Section Q referrals based on the resident’s answers in Section Q of the MDS.

Resident’s can accept OR decline visit.

WHO DO WE VISIT?

If a resident/family is considering transitioning out of a nursing home, a MFP staff person meets with them (and the family) to discuss their care needs and possible community based service options.

If the individual (and family) is interested in pursuing discharge, a referral is made to the nursing home discharge planner.

At the request of the resident/family, MFP staff can attend discharge planning meetings to further discuss available community based options and how to access them.

MFP staff can also follow up on referrals made to community resources if the resident/family requests.

How Does the Process Work?

Adult Day Programs

Assisted Living

Homecare OptionsMeals/Nutrition OptionsHousing

Utility/Weatherization Assistance

Assistance With Household Chores

Transportation

Resources Specific To Their Community

What Types of Information Does the Participant Receive?

Depending on their specific needs, participants may receive information about:

A referral indicating a resident’s interest in transitioning is made to the nursing home discharge planner.

Information provided to the resident/family is also shared with the discharge planner/social worker.

At the resident’s request, MFP staff will collaborate with the discharge planner & follow up on any referrals made.

The goal is to educate the resident and family about potential community based services that may be available to them & assist them in the process of transitioning back into the community.

What Happens If The Resident Is Interested In Transitioning Back To The Community?

Meeting with or receiving information from MFP representatives will not affect a resident’s status at the nursing home in ANY way.

If a resident decides to remain in the nursing home, he or she can always ask to meet with MFP at a later time should they want to reconsider discharge from the nursing home.

What Happens if the Resident Chooses to Remain in the Nursing Home?

Residents receive objective information

about community based services and

long term care options that may be

available to them and they decide to remain

where they are.

Families receive the objective

information and keep it for

consideration at a later time.

Residents successfully

transition from the nursing home back into the community with the necessary community based services in place.

Outcomes

How long does the process take?

The length of time the process takes for each

resident varies depending on their

individual needs and the sophistication &

availability of the services required.

What are some of the potential barriers to a successful transition?

Lack of appropriate, affordable housing.

Availability of community based and homecare

services

The person may not be eligible for the program or service they are interested

in receiving.

Frequently Asked Questions

Does MFP replace the nursing home’s discharge

planning?

NO -- MFP works as an adjunct to the discharge planning provided by the

nursing home.

How is MFP different than NHTD?

MFP provides objective information about a wide

variety of community based services and long term care

options in each of the counties it serves.

NHTD – Nursing Home Transition and Diversion is a

specific Medicaid Waiver program that provides

additional services (waiver services) in addition to

traditional services funded by Medicaid (state plan services).

Frequently Asked Questions-Cont.

Money Follows the Person Demonstration Project

• 29-01 216 Street • Bayside, NY 11360• MAIN PHONE: (718) 281-8800

St. Mary’s Healthcare System

• PHONE: (718) 281-8752• FAX: (516) 240-6436• EMAIL: [email protected]

Christine Duffy, Program CoordinatorMoney Follows the Person Demonstration Project

This document was developed under grant CFDA 93.791 from the U.S. Department ofHealth and Human Services, Centers for Medicare & Medicaid Services. However, thesecontents do not necessarily represent the policy of the U.S. Department of Health andHuman Services, and you should not assume endorsement by the Federal Government.