Money Follows the Person Quarterly Stakeholder Meeting

October 23, 2013

Agenda
■	Welcome
■	MFP Data
■	Transition Coordination Entities
■	MFP Waiver Update
■	MFP Training Update
■	MFP Housing Update
■	Discussion
Demonstration Benchmark
Data

Graph showing the number of MFP participants in the community by population as of 9/30/2013
•	283 elders
•	38 individuals with ID/DD
•	99 individuals with physical disabilities 
•	24 individuals with mental illness 

Graph showing the number of MFP participants in the community by qualified facility as of 9/30/2013

•	384 individuals from Nursing Facilities
•	23 individuals from ICF/MR
•	37 individuals from Chronic or Rehab Hospitals

Graph showing the number of transitions by type of community residence as of 9/30/2013

•	96 individuals to homes owned by the participant 
•	82 individuals to homes owned by a family member 
•	159 individuals to apartments leased by participant
•	3 individuals in assisted living
•	104 individuals to group homes of 4 persons to less

Transition Coordination Entities

Transition Coordination functions:

•	Engagement
•	Enrollment
•	Transition Planning
•	Provision of Necessary Goods and Services
•	Housing Search
•	Coordination with Case Managers
•	Conducting Baseline Quality of Life Survey

Transition Coordination Entities
•	 Engagement
•	Provide outreach to individuals in MFP Qualified Facilities and inform them about the availability of the MFP Demo
•	Accept Referrals for Potential MFP Demo Enrollees 
•	 Enrollment
•	Clarify the individual is eligible for MFP
•	Have individual sign the Informed Consent Form 
•	Assist individuals, face to face, to enroll in the MFP Demonstration and verify their MassHealth eligibility
•	Include whether MFP Enrollee has an ABI in IS system

Transition Coordination Entities
■	Transition Planning
•	Provide assistance to individuals enrolled in the MFP Demo to understand the range of community-based services and options that may be available to them
•	Assist individuals in identifying and applying for Home and Community-Based Services (HCBS) Waivers for which they may be eligible
•	Refer those who do not enroll in one of the HCBS Waivers for MFP Demo case management
•	Based on individual choice, TE may refer to either:
•	To Massachusetts Rehabilitation Commission (MRC) or 
•	To an ASAP 
•	Develop person-centered transition plans to map out what the individual needs and how it will be arranged and provided

Transition Coordination Entities
•	Transition Coordination 
•	Coordinate transitions from facilities to community-based settings 
•	Arrange for and/or provide MFP Demonstration Transitional Assistance Services
•	MFP Demonstration Transitional Assistance Services (i.e. necessary goods and services)
•	Shopping for, purchasing or providing necessary goods and services that are needed to make the move to the community including:
•	One-time costs like setting up utilities, security deposit, furnishings
•	Home Modifications
•	Housing Search

MFP Demonstration Transitional Assistance Services (con’t)
•	Housing Search
•	Linkage with Housing Search Entities who can assist in locating and applying for housing
•	Assisting with/providing transportation for viewing housing options
•	Coordination with Case Managers
•	Work with the Case Manager who is assigned through an HCSB waiver agency, or an MFP Demonstration Case Manager and any other case managers (for example DMH case managers)
•	Conduct baseline MFP Demonstration Quality of Life Survey

Case Manager – Transition Coordinator Collaboration
•	Once a waiver or Demo case manager is identified collaboration between the case manager and the transition coordinator begins  
•	The transition coordinator is responsible for coordinating the MFP Demonstration Services, including Transitional Assistance Goods & Services when appropriate; this can include Demo services provided after facility discharge
•	The case manager is responsible for arranging and overseeing the delivery of waiver services and other community long-term care services 
•	The transition coordinator and case manager will collaborate with other state agencies who may be involved with the MFP Demo participant

Division of Duties– Pre-Discharge 

Transition Coordinator

■	Outreach to MFP qualified facilities & individuals in them
■	Determine if individuals meet MFP Demo criteria
■	Obtain Signed Informed Consent
■	Facilitate MassHealth enrollment if necessary
■	Assist individuals to understand the range of available community-based services and options
■	Refer Demo participants for HCBS waiver eligibility or for Demo Case Management
■	Develop Person-Centered Transition Plan including Demo services needed
■	Link Demo participants with qualified HSEs when needed and assist with or provide transportation
■	Conduct baseline Quality of Life Survey

Case Manager
■	Collaborate as needed with Transition Coordinator to support the facilitation of the Enrollee/Participant’s discharge
■	Continue the person-centered planning process begun by the Transition Coordinator to ensure that all needed community-based long term services and supports (LTSS) are identified
■	Based on Person-Centered Transition Plan, begin development of detailed Individualized Service Plan and 24-Hour back-up plan to ensure that LTSS are appropriate, and will be in place at discharge

Division of Duties – In the Community

Transition Coordinator
■	In collaboration with the Case Manager, arrange for the provision of Demo services as necessary throughout the participant’s first 365 days in the community
■	Collaborate with Case Managers to ensure ongoing successful residency in  the community
■	Collaborate with Case Manager and other state agencies who may be involved with the MFP Demo participant

Case Manager
■	Provide ongoing oversight and monitoring of services ensuring waiver and/or state plan service delivery, appropriateness, and participant satisfaction
■	Make changes to the individual’s plan for community services as needed by the participant
■	Collaborate with the Transition Coordinator and other state agencies who may be involved with the MFP Demo participant
■	Conduct Quality of Life Survey at 11 Months and 24 Months

Transition Coordination Entities
■	Aging and Disability Resource Consortium of the Greater North Shore, Inc.
■	BayPath Elder Services, Inc. 
■	Boston Center for Independent Living
■	Boston Senior Home Care
■	Bristol Elder Services
■	Center for Living & Working, Inc.
■	Central Boston Elder Services
■	Chelsea Revere Winthrop Home Care Center Inc.
■	Coastline Elderly Services, Inc.
■	Cape Organization for Rights of the Disabled (CORD)
■	Elder Services of Berkshire County, Inc.
■	Elder Services of Cape Cod and the Islands, Inc.
■	Elder Services of the Merrimack Valley, Inc.
■	Elder Services of Worcester Area, Inc.
■	Southwest Boston Senior Services, Inc. d/b/a Ethos
■	Franklin County Home Care Corporation
■	Greater Springfield Senior Services, Inc.
■	Health and Social Service Consortium, Inc. HESSCO Elder Services
■	Highland Valley Elder Services, Inc. 
■	Independence Associates, Inc.
■	MetroWest Center for Independent Living, Inc.
■	Minuteman Senior Services
■	Montachusett Home Care Corporation
■	Mystic Valley Elder Services, Inc. 
■	Northeast Independent Living Program, Inc.
■	Old Colony Elder Services, Inc. 
■	Southeast Center for Independent Living, Inc.
■	Somerville-Cambridge Elder Services 
■	South Shore Elder Services, Inc. 
■	Springwell 
■	Stavros Center for Independent Living, Inc. 
■	Tri-Valley, Inc. 
■	WestMass ElderCare, Inc. 

Transition Coordination Entities: Transition Projections for CY 2014
				
Aging and Disability Resource Consortium of the Greater North Shore, Inc., 55 transitions 
BayPath Elder Services, Inc.,15 transitions  
Boston Center for Independent Living
Boston Senior Home Care, 54
Bristol Elder Services, 25
Center for Living & Working, Inc.
Central Boston Elder Services, 5
Chelsea Revere Winthrop Home Care Center Inc.,5
Coastline Elderly Services, Inc., 10 
Cape Organization for Rights of the Disabled (CORD),8 
Elder Services of Berkshire County, Inc., 10
Elder Services of Cape Cod and the Islands, Inc., 1 
Elder Services of the Merrimack Valley, Inc., 13
Elder Services of Worcester Area, Inc., 20
Southwest Boston Senior Services, Inc. d/b/a Ethos, 6
Franklin County Home Care Corporation, 4 
Greater Springfield Senior Services, Inc., 18
Health and Social Service Consortium, Inc. HESSCO Elder Services, 9
Highland Valley Elder Services, Inc., 2  
Independence Associates, Inc., 18
MetroWest Center for Independent Living, Inc., 12
Minuteman Senior Services, 9
Montachusett Home Care Corporation, 9
Mystic Valley Elder Services, Inc. 
Northeast Independent Living Program, Inc., 10 
Old Colony Elder Services, Inc., 48 
Southeast Center for Independent Living, Inc.
Somerville-Cambridge Elder Services, 12  
South Shore Elder Services, Inc., 75 
Springwell, 20 
Stavros Center for Independent Living, Inc., 15 
Tri-Valley, Inc., 6
WestMass ElderCare, Inc., 10 

MFP Waiver Update

MFP Demonstration Participants may access services through: 
•	The MassHealth State Plan including:
•	State Plan LTSS – PCA, AFC, ADH, etc. 
•	SCO or PACE 
•	One Care or other State Plan services
•	HCBS waivers including: 
•	Frail Elder Waiver
•	MFP Community Living Waiver
•	MFP Residential Supports Waiver
•	ABI Residential Habilitation Waiver 
•	ABI Non-Residential Habilitation Waiver 
•	DDS Intensive Supports Waiver
•	DDS Community Living Waiver
•	DDS Adult Supports Waiver  

HCBS Waiver Capacity Status 
•	Frail Elder: available  
•	MFP Community Living: available 
•	MFP Residential Supports: at capacity for this waiver year
•	ABI Residential Habilitation Waiver: available  
•	ABI-Non Residential Habilitation Waiver: at capacity for this waiver year 
•	DDS Intensive Supports Waiver: available  
•	DDS Community Living Waiver: available 
•	DDS Adult Supports Waiver: available 

MFP Training Update

MFP Transition Entity Training
Transition Entity Training has been on-going since Mid-October, encompassing:
•	MFP Information System (IS)
•	MFP Demonstration, Transition Coordination and Waiver Overview
•	MFP Demonstration Transition Entity Payment and Claims Overview
•	MFP On-Line Training Modules

MFP Information System (IS)
Comprehensive instruction on how to use the MFP-IS application on the EOHHS Virtual Gateway to add, manage, and track Enrollees and Participants from enrollment through completion or disenrollment. 

•	October 1 – 16, 2013
•	9 Training Sessions
•	91 Individuals Trained
•	Excellent Participant Questions and Feedback

MFP Training Update

The MFP Information System:
•	The MFP-IS is a web-based application used to record, maintain and track information about MFP Enrollees and MFP Participants in the community
•	The MFP-IS is NOT a case management or client information system 
•	It allows users to keep track of Enrollees, data about them, changes in their status, dates of enrollment and transitions, quality of life surveys and other information required to report MFP data appropriately to CMS

MFP Demonstration, Transition Coordination and Waiver Overview

Complete overview of the MFP Demonstration for transition entity staff including transition services and supports available to Enrollees and Participants.
•	October 22 – November 1, 2013
•	6 Training Sessions (AM) and Locations
•	October 22 - Central Boston Elder Services, Boston
•	October 25 – Independence Associates, Brockton
•	October 28 – North Shore Elder Services, Danvers
•	October 30 – Bristol Elder Services, Fall River
•	October 31 – Greater Springfield Senior Services, Springfield
•	November 1 – UMass Medical School, Shrewsbury 
•	95 individuals are registered to attend

MFP Demonstration, Transition Coordination and Waiver Overview

Topics
•	MFP Demonstration Overview
•	Transition Coordination Overview
•	Quality of Life Survey
•	MFP Demonstration Services, including Housing Search Assistance
•	HCBS Waivers and MassHealth State Plan service options

MFP Payment and Claims Training
Overview of the MFP Demonstration provider payment and claiming process for staff responsible for agency billing activity. 
•	October 22 – November 1, 2013
•	6 Training Sessions (PM) and Locations
•	October 22 - Central Boston Elder Services, Boston
•	October 25 – Independence Associates, Brockton
•	October 28 – North Shore Elder Services, Danvers
•	October 30 – Bristol Elder Services, Fall River
•	October 31 – Greater Springfield Senior Services, Springfield
•	November 1 – UMass Medical School, Shrewsbury 
•	70 individuals are registered to attend

MFP On-Line Training Modules

Module series created to provide transition coordinators with a general overview of the MFP Demonstration including goals, benefits, participant eligibility requirements, and how individuals will receive long term supports and services through existing and new HCBS programs. 

Current on-line training modules include:
•	MFP Demonstration Grant
•	Administering the Quality of Life Survey
•	MA State Plan Services
•	MA HCBS Waivers
•	Executive Office of Health and Human Services Overview

Note: Additional training modules are in development. 

MFP Housing Update 

Referrals for Housing Search
•	When a MFP Demo participant is interested in housing in the community, the participant should be referred to the Qualified Housing Search Entity (HSE) of their choice
•	When referring an MFP Demo participant for housing, the Transition Entity (TE) will utilize the Referral for Housing Search and Services Form 
•	The HSE must accept or deny a referral within 3 business days
•	When the HSE and TE are the same organization: The participant must be given a choice of HSE – the participant should not be automatically referred to the HSE in the organization that is providing transition coordination.

MRC Qualified HSEs 
•	Aging & Disability Resource Consortium of the Greater No. Shore – Northern Region
•	Advocates – Greater Boston, Central, Southeast Regions
•	AIDS Action Committee – Greater Boston Region
•	Hearth, Inc. – Greater Boston Region
•	Housing Assistance Corporation – Greater Boston Region
•	Independence Associates – Southern Region
•	Metropolitan Boston Housing Partnership -  Greater Boston Region
•	Metrowest Center for Independent Living – Central Region 
•	Northeast Independent Living Program – Northern Region
•	South Middlesex Opportunity Council – Central Region
•	Stavros Center for Independent Living – Western Region 

More Information on MFP 
■	MFP Website: http://www.mass.gov/eohhs/consumer/disability-services/living-supports/community-first/money-follows-the-person-rebalancing-grant.html
■	Information you will find:
•	MFP Planning Grant documents
•	MFP Project Summary and Operational Protocol
•	Past MFP Presentations (PPT and RTF)
•	Upcoming meeting announcements

■	Please contact MFP@state.ma.us if you have further questions or would like to be added to our mailing list for announcements of future MFP meetings