CT Department of Mental Health and Addiction Services OLDER ADULT SERVICES UNIT RESOURCE GUIDE

Transcription

1 CT Department f Mental Health and Addictin Services OLDER ADULT SERVICES UNIT RESOURCE GUIDE fr clients served under the Nursing Hme Diversin and Transitin Prgram Updated

2 RESOURCE GUIDE TABLE f CONTENTS TOPIC PAGE(S) Overview f the CT Department f Mental Health and Addictin Services 3 DMHAS Older Adult Services 4 DMHAS Nursing Hme Diversin and Transitin Prgram 5 WISE: Mental Health Waiver 6-8 DMHAS Reginal Managers 9 Older Adult Substance Abuse Services Staff (Senir Outreach) 10 Gatekeeper Prgram 10 CT Resurces fr Older Adults with C-ccurring Mental Health And Substance Abuse Prblems 11 Geriatric Assessment Resurces in CT DMHAS Lcal Mental Health Authrities (LMHAs) DMHAS Crisis Services 15 DMHAS Respite Beds DMHAS Hmeless Services 18 CT Hme and Cmmunity-based Services Waivers 19 Other Resurces Nursing Hme Placements/Preadmissin Screening Resident Review (PASRR) 22 APPENDIX: Map f Cnnecticut/LMHA Lcatins Staff Cntacts fr Nursing Hme Diversin and Transitin Prgram (as f ) 2

3 Overview f the CT Department f Mental Health and Addictin Services (Substance Abuse & Mental Health Authrity fr State f CT) Cmmissiner s Office 410 Capitl Avenue (4 th flr) P.O. Bx Hartfrd, CT Main Telephne: Cmmunity Call Line: Mandate: 1. T serve adults age 18 and lder with psychiatric r substance abuse disrders, r bth, wh lack the financial means t btain such services n their wn. 2. T prvide Preventin Services t ALL Cnnecticut citizens. Department includes: 1. In-patient facilities a. Cnnecticut Valley Hspital (CVH) in Middletwn b. Blue Hills Hspital (treats substance abuse) in Hartfrd c. Greater Bridgeprt Cmmunity Mental Health Center in Bridgeprt d. CT Mental Health Center in New Haven f. Capitl Regin Mental Health Center in Hartfrd Lcal Mental Health Authrities (LMHAs) respnsible fr cmmunity care at lcal level (see pages and Appendix fr Map f CT) Examples f Special Prgrams: (see DMHAS website fr details) 1. Acquired Brain Injury Prgram (ABI) 2. Prblem Gambling Services 3. HIV/AIDS 4. Special Educatin 5. Military Supprt Prgram 6. Yung Adult Services 7. Older Adult Services (Mental Health Waiver; Nursing Hme Diversin & Transitin Prgram; PASRR) T apply fr services: 1. Mental Health cntact LMHA (see pages r visit DMHAS website) 2. Substance Abuse cntact specific prgram (see DMHAS website) 3

4 Department f Mental Health and Addictin Services Older Adult Services CVH, Beers Hall, 3 rd Flr P.O. Bx 351 Middletwn CT Missin 1. T educate cnsumers, prviders, and ther interested individuals abut the mental health need f lder adults, as well as prmting evidenced-based treatment practices; 2. T implement and perate the Medicaid Hme and Cmmunity-based Waiver fr Persns with serius Mental Illness; and 3. T ensure that nursing hme placements fr DMHAS clients are necessary, apprpriate, and safe. Overview f Services Older Adult Services Older adults have nt been the fcus f the public health system until recently. T bring mre attentin t this ppulatin, we are educating cnsumers, prviders, and ther interested individuals abut the needs f lder adults with respect t mental health and substance abuse. Currently, we are cnducting classes under the DMHAS Educatin and Training Divisin and cnducting wrkshps at varius state cnferences. Additinally, DMHAS ffers tw specific prgrams statewide fr adults age 55 and ver: the Gatekeeper Prgram, which is an evidenced-based practice t identify at-risk lder adults in the cmmunity and the Senir Outreach Substance Abuse Prgram. Nursing Hme Diversin and Transitin Prgram The purpse f this prgram is t ensure the nursing hme placements fr DMHAS are necessary, apprpriate, and safe. PASRR (Preadmissin Screening Resident Review) is an integral part f the prgram. The prgram fcuses n tw gals: (1) Reduce admissins t nursing hmes; and (2) Mnitring admissins that d ccur fr apprpriate placement and/r eventual discharge back t the cmmunity with supprt services. DMHAS funds eight Nurse Clinicians and tw case managers wh wrk directly with cmmunity prviders, nursing hmes, and hspital discharge planners, bth inpatient and in the emergency rm. Waiver fr Integratin, Supprt and Empwerment (WISE) Fr individuals with serius mental illnesses, this prgram encmpasses the recvery rientatin adpted by DMHAS and als signals new directins in the cmmunity treatment f persns with serius psychiatric disabilities. Authrized under 1915(c) f the Scial Security Act, the waiver permits the State t furnish an array f hme and cmmunity-based services that assist Medicaid beneficiaries t live in the cmmunity, aviding institutinal care. Waiver Services cmplement and/r supplement services available thrugh the Medicaid State Plan and ther federal, state, and lcal public prgrams, as well as natural supprts that families and cmmunities prvide. The waiver will serve 216 individuals ver three years. These individuals are currently in nursing hmes r at-risk fr institutinal care. The waiver is perated by DMHAS with versight by DSS. The service package is included in this manual. 4

5 Department f Mental Health and Addictin Services Nursing Hme Diversin and Transitin Prgram (NHDT) Gal: T ensure that DMHAS clients are nt placed in, r remain in, nursing hmes unless necessary, apprpriate, and safe. Preadmissin Screening Resident Review (PASRR) is an integral part f the prgram. Objectives: 1) Divert DMHAS clients frm nursing hme placement unless abslutely necessary (i.e.; persn culd nt be served in the cmmunity due t a need fr cntinuus skilled nursing services related t a chrnic cnditin, r requires shrt-term rehabilitatin fr a medical cnditin). 2) Transitin back t the cmmunity DMHAS clients wh reside in nursing hmes and n lnger require the level f care. NHDT Prgram Structure: 1) Prgram is hused in the DMHAS Older Adult Services Unit. 2) Staff includes a Prgram Manager, Nurse Clinicians, and Case Managers. The Nurse Clinicians and Case Managers are lcated at DMHAS-funded agencies (see Attachment fr names f the clinicians, cverage areas, and cntact infrmatin). Staff Functins: 1) Nurse Clinicians: Act as liaisns fr clients eligible fr DMHAS services thrugh Lcal Mental Health Authrities and the Mental Health Waiver, as well as ther initiatives (e.g., Mney Fllws the Persn) r agencies prviding services t clients. Wrk directly with cmmunity prviders, nursing hmes, and discharge planners (bth inpatient and in emergency rms) t determine the apprpriate level f care fr DMHAS clients. Link with PASRR Prgram by assisting DMHAS and ther prviders in determining whether client applying t a nursing hme meets level f care criteria, and fr clients wh enter a nursing hme with a shrt-term apprval, mnitr and track length f stay fr pssible transitin t the cmmunity. 3) Case Managers: Supprt the wrk f the Nurse Clinicians as abve. QUESTIONS? Jennifer Glick, RN, MSW NHDT & PASRR Prgram Manager Older Adult Services Beers Hall P.O. Bx 351 Middletwn, CT Office: Cell: Jennifer.glick@ct.gv 5

6 WISE Wrking fr Integratin Supprt and Empwerment The Mental Health Hme and Cmmunity Based Services (HCBS) Waiver (Revised as f April 1, 2012) The waiver prgram fr individuals with serius mental illness encmpasses the recvery rientatin adpted by the Department f Mental Health and Addictin Services (DMHAS), but als signals new directins in the cmmunity treatment f peple with serius psychiatric disabilities because f its emphasis n: Intensive psychiatric rehabilitatin prvided in the participant s hme, and in ther cmmunity setting; Attentin t bth psychiatric and medical needs; Emphasis n wellness and recvery; Persn-Centered Planning leading t develpment f an individualized Recvery Plan; and Use f peer supprts prvided by peple trained and certified in rehabilitative care, wh knw frm first-hand experience abut recvery frm mental illness. The waiver prgram, authrized in 1915(c) f the Scial Security Act, permits the State t furnish an array f hme and cmmunity-based services that assist Medicaid beneficiaries t live in the cmmunity and avid institutinal care. Waiver services cmplement and/r supplement services available t participants thrugh the Medicaid State plan and ther federal, state and lcal public prgrams, as well as natural supprts that families and cmmunities prvide. The Waiver is perated by the DMHAS with versight by the Department f Scial Services (DSS). The waiver prgram serves eligible individuals transitining ut f nursing facilities r wh are at risk fr this level f care. Each persn enrlled in the waiver participates in a Persn-Centered Planning prcess leading t the develpment f an individualized Recvery Plan. The plan, develped cllabratively with the participant and a DMHAS Cmmunity Supprt Clinician includes ne r mre f the fllwing services: Rehabilitative Services and Supprt Services: Cmmunity Supprt Prgram (CSP) A flexible, team-based apprach t cmmunity rehabilitatin. Peer Supprt An alternative r step-dwn and fllw-up t CSP prvided by a trained and certified peer specialist. Recvery Assistant hmemaker, cmpanin, persnal care, and in-hme respite services deigned t help a participant maintain his/her wn hme. Supprted Emplyment an effective array f mental health supprts designed t help participants find and sustain cmpetitive emplyment. 6

7 Transitinal Case Management services prvided during the weeks prir t, and immediately fllwing discharge frm a nursing hme, t help lcate and set up a suitable apartment r ther living arrangement. Brief Episde Stabilizatin services designed t stabilize a participant in an emerging crisis situatin r fllwing discharge frm a institutinal level f care. Residential Based Services: Assisted Living Agency Persnal care and services prvided in a licensed cmmunity care facility, prvided t residents f the facility. This service includes 24-hur n-site respnse staff. Cmmunity Living Supprt Services Supprt Services, including vernight supervisin, necessary t enable a participant t live in a shared apartment, r independent residential setting in the cmmunity. Other Ancillary Services: Specialized Medical Equipment Hme Accessibility Adaptatins Nn-medical transprtatin Client Eligibility fr Mental Health Waiver Participants must meet all f the requirements f Sectin 1, and ne f the requirements f Sectin 2: Sectin 1 (all f the fllwing five requirements) 1. An adult, 22 years f age r lder; 2. Wh is Medicaid eligible; 3. Meets the Medicaid State Plan criteria fr nursing hme level f care; 4. Vluntarily chses t participate in the waiver; and 5. Has a diagnsis f serius mental illness as defined by State f Cnnecticut PASRR plicy. Sectin 2 (ne f the fllwing three requirements) 1. Is currently a resident f a nursing facility; 2. Is a participant in mney Fllws the Persn (MFP); r 3. Has a psychiatric histry, impairment and service needs as evidenced by the fllwing: Has a histry f: Tw r mre inpatient psychiatric hspitalizatins in the past tw years; r A single inpatient psychiatric inpatient hspitalizatin lasting 30 cnsecutive days r mre in the past tw years; r Three crisis episdes in the past year requiring face-t-face assessment, but nt necessarily requiring inpatient hspitalizatin. 7

8 Is currently experiencing tw r mre f the fllwing circumstances due t serius mental illness: Has been recmmended t take, r currently uses prescribed medicatin t cntrl psychiatric symptms; Is unable t wrk in a full-time cmpetitive emplyment situatin; Requires n-ging supervisin and supprt t maintain a cmmunity living arrangement; Is hmeless, r at-risk fr hmelessness; Has had, r will predictably have, repeated episdes f decmpensatin such as increased symptms f psychsis; self-injury; suicidal/hmicidal ideatin; r psychiatric hspitalizatin. Additinally Has a level f risk t self r thers that a licensed mental health prfessinal has determined can be managed safely in the cmmunity. Have the fllwing cre services needs, if living in the cmmunity: 1. One-n-ne rehabilitative activities in the hme r in ther cmmunity settings t assist in managing psychiatric, substance use, r medical prblems, and in meeting requirements f everyday independent living; and 2. Supprt Crdinatin t assist in develping and implementing a Recvery Plan that ensures psychiatric and/r medical needs are met. MH Waiver Applicatin Referral Prcess 1. Applicatin/ Request fr Service submitted t MH Waiver Prgram 2. Medicaid eligibility verified by DSS 3. Assessment cnducted by a Waiver Cmmunity Supprt Clinician (CSC) t cnfirm eligibility 4. Recvery Plan develped including: services needed, assurance f cst neutrality and cmmunity safety 5. Plan and crrespnding services submitted by Waiver staff t DSS fr apprval 6. Recvery Plan implemented with Waiver Service Prviders selected by participant 7. Payment fr Services as utlined in Recvery Plan are authrized by Waiver Staffreviewed quarterly Cntact Megan Gdfield (860) r tll free r megan.gdfield@ct.gv 8

9 DMHAS Reginal Managers The state is divided int 5 regins. Listed belw are the managers fr each regin wh can assist with finding mental health, substance abuse & prblem gambling services. Regin 1: Manager: Wayne Starkey, , wayne starkey@ct.gv Bridgeprt, Darien, Eastn, Fairfield, Greenwich, Mnre, New Canaan, Nrwalk, Stamfrd, Stratfrd, Trumbull, Westn, Westprt, Wiltn. Regin 2: Manager: Wayne Starkey, wayne.starkey@ct.gv Ansnia, Bethany, Branfrd, Chester, Clintn, Crmwell, Deep River, Durham, East Haddam, East Haven, Essex, Guilfrd, Haddam, Hamden, Killingwrth, Lyme, Madisn, Meriden, Middlefield, Middletwn, Milfrd, New Haven, Nrth Branfrd, Nrth Haven, Old Lyme, Old Saybrk, Orange, Oxfrd, Prtland, Seymur, Sheltn, Wallingfrd, Westbrk, West Haven, Wdbridge. Regin 3: Manager: Rhnda Kincaid, , rhnda.kincaid@ct.gv Ashfrd, Bzrah, Brklyn, Canterbury, Chaplin, Clchester, Clumbia, East Lyme, Eastfrd, Franklin, Griswld, Grtn, Hamptn, Killingly, Lebann, Ledyard, Lisbn, Mansfield, Mntville, New Lndn, Nrth Stningtn, Nrth Plainfield, Pmfret, Putnam, Salem, Sctland, Sprague, Sterling, Stningtn, Thmpsn, Unin, Vluntwn, Waterfrd, Willingtn, Windham, Wdstck. Regin 4: Manager: Michael Michaud, , michael.michaud@ct.gv Andver, Avn, Berlin, Blmfield, Bltn, Bristl, Burlingtn, Cantn, East Granby, East Hartfrd, East Windsr, Ellingtn, Enfield, Farmingtn, Glastnbury, Granby, Hartfrd, Hebrn, Kensingtn, Manchester, Marlbrugh, New Britain, Newingtn, Plainville, Plymuth, Rcky Hill, Simsbury, Smers, Suth Windsr, Suthingtn, Staffrd, Suffield, Tlland, Vernn, West Hartfrd, Windsr, Windsr Lcks Regin 5: Manager: Rhnda Kincaid, , Rhnda.kincaid@ct.gv Barkhamsted, Beacn Falls, Bethel, Bethlehem, Bridgewater, Brkfield, Canaan, Cheshire, Clebrk, Crnwall, Danbury, Gshen, Hartland, Kent, Litchfield, Middlebury, Mrris, Naugatuck, New Fairfield, New Hartfrd, New Milfrd, Newtwn, Nrflk, Nrth Canaan, Oxfrd, Prspect, Redding, Ridgefield, Rxbury, Salisbury, Sharn, Sherman, Suthbury, Thmastn, Trringtn, Warren, Washingtn, Waterbury, Watertwn, Winchester, Winsted, Wlctt, Wdbury. 9

10 Further Questins? Call the DMHAS Cmmunity Call Line: Patrick Tuckey, Older Adult Substance Abuse Services Staff Thrugh cntract agencies, the Department f Mental Health and Addictin Services prvides cnsultatins and educatin, utreach, hme visits, nursing hme visits, and age-specific weekly substance abuse grup therapy t Older Adults thrughut the state. William Gnzalez, Med, LADC Liberatin Prgram Stamfrd, Bridgeprt area Mary Garfal, DARC, MSW Wheeler Clinic Plainville, Manchester area Glen Ryan, CADC McCall Fundatin Trringtn, CT Debrah, Gregg, BS Alchl and Drug Recvery Center (ADRC) Hartfrd, New Britain area Craig Simmns Cmmunity Health Services Hartfrd, CT Edwina Ranganathan, MSW, LADC Rushfrd Center Middletwn, CT Jim Crean MCCA Danbury, CT Cindy Everett-Simpsn, ICAC, SCCP (x225) SCADD New Lndn, Nrwich area Gatekeeper Prgram This prgram educates the cmmunity (pstal wrkers; beauticians; hme delivery wrkers; etc.) hw t identify and refer lder adults (age 55+) wh may need assistance t remain safe in their hmes. A Gatekeeper Prgram can be called fr fllw-up. Prgrams are lcated in the fllwing regins (see page 9 fr specific twns in the regins) and agencies: Regins 1 & 5 Regin 2 Gatekeeper 8 (Mental Health Assciatin) St. Luke s Eldercare Services Tll Free: ASK-GATE ( ) Regin 3 Regin 4 10

11 United Services Gatekeeper Prgram CRT Senir Services Gatekeeper Prgram CT Resurces fr Older Adults with C-ccurring Mental Health and Substance Abuse Prblems New Prspects: 392 Prspect Street, Bridgeprt Tel: Serves adult men and wmen with high severity f substance use and lw t mderate severity f mental health symptms in need f shrt-term treat f apprximately 30 days. Accepts referrals statewide. Equal access t treatment fr all persns in need, regardless f race, ethnicity, gender, age, disability, surce f payment, and sexual rientatin. DMHASfunded. MCCA McDnugh Huse: 38 Ridgebury Rad, Danbury Tel: Serves persns with c-ccurring mental and substance abuse disrders, including senirs/lder adults. Shrt and lng-term residential treatment. Frms f payment: self-pay (sliding scale based n incme & ther factrs); private insurance; Medicaid. MCCA Trinity Glen: 149 West Crnwall Rad, Sharn Tel: Residential lng-term treatment (mre than 30 days) fr men and wmen, including senirs/lder adults, wh need substance abuse services. Frms f payment: self-pay r private insurance. SCADD Lebann Pines: 37 Camp Mween Rad, Lebann Tel: Lng term treatment fr men with substance abuse prblems. Minimum length f stay is 90 days. Liberatin Prgrams, Inc.: 780 Summer Street, Stamfrd Cntact Bill Gnzalez abut his utpatient grup f lder adults: Wheeler Clinic Senir Substance Abuse Services: Plainville Tel: Serves lder adults age 60 plus wh have substance abuse issues. Merritt Hall at CT Valley Hspital: Middletwn Tel: (Prgram may n lnger be available due t lay-ffs July 2011) Usually treats ages 25-40ish, but lder persn wh has a primary substance abuse diagnsis n Axis I, is withut a majr psychtic disrder, and can attend 6-7 grups per day may be apprpriate; LOS averages days; T-19 accepted, but clients usually indigent/uninsured. 11

12 Greenwich Hspital: Addictin Recvery/ Older Adult Detx Prgram Tel: Geriatric Assessment Resurces in CT Day Kimball Healthcare Geriatric Care Management Prgram: Pmfret Street, Putnam, CT Adults age 60 and ver are eligible. Referral frm wn physician is suggested. Offers cmprehensive evaluatin, planning and care crdinatin fr senirs, their families and health care prviders. The gal is t assist the elderly and their caregivers t manage chrnic illness and high risk cnditins in rder t imprve health, safety and functin. The Department f Veterans Administratin (VA) VA CT Healthcare System (1) West Haven VA (in- and ut-patient prgrams) 950 Campbell Avenue, West Haven (Nursing Hme Prgram ext. 3940) (2) Newingtn VA (ut-patient prgrams) 555 Willard Avenue, Newingtn All Veterans enrlled in the VA health care system are eligible fr hme and cmmunity based lng term care services. Hspital f Saint Raphael, New Haven Healthy Aging Htline fr Senir Services: (variety f services) Hspital f Central CT, New Britain and Suthingtn New Britain campus: (in & utpatient services fr mental illness & substance abuse & Older Adult Prgrams) Suthingtn campus: (Center fr Health Aging) The Institute f Aging, Fairfield Jeffersn Street, Fairfield, CT Specializes in examining, diagnsing and treating cgnitive r memry functin. Assessments available in the client s hme, at the IOA clinic, r ther lcatin cnvenient t the client. Clients seen within 2 weeks f initial cntact. Accepts Medicare, lng-term care insurance, r private pay. Institute f Living/Hartfrd Hspital, Hartfrd Geriatric Prgram (in & utpatient) 12

13 The Institute f Living Assessment Center r tll-free Seymur Street, Hartfrd, CT Wrk in cnsultatin with wn physician. Geriatric Assessment Resurces in CT cntinued Masnicare Primary Care Physicians, Wallingfrd 67 Masnic Avenue, Wallingrd, CT General Healthcare and Well-being Services r tll-free A geriatric assessment is an utpatient appintment, which usually takes apprximately 1-1/2 t 2 hurs. It includes a fllw-up reprt t the patient s wn physician. Saint Francis Hspital, Hartfrd Wdland Street, Hartfrd Prvide cmprehensive geriatric evaluatins. UCnn Health Center, Center n Aging, Farmingtn Main: Appintments: (UCnn Geriatric Assciates) Office hurs Mnday-Friday, Farmingtn Avenue, Farmingtn, CT Prvides primary care fr lder adults n the Farmingtn campus and ther lcatins; cnsultative and specialty services als available. Yale New Haven Hspital, New Haven Drthy Adler Geriatric Assessment Center: Hward Avenue, New Haven, CT Persn receives a cmprehensive medical exam and diagnstic testing is dne as an utpatient at YNHH r at the patient s preferred site. Team wrks clsely with patient s wn physician. 13

14 Department f Mental Health and Addictin Services Lcal Mental Health Authrities (LMHAs) LMHAs have the authrity and respnsibility fr planning, delivering, and managing a variety f DMHAS-funded mental health services at the lcal level. Each LMHA cvers a specific gegraphic area f the state. Please check the DMHAS website at t check the LMHA that cvers yur twn. LMHA & Lcatin Main Telephne Diversin Nurse Suthwest CT Mental Health System: SWCCA: Sue Westerberg will cver ( ) F.S. DuBis Center in Stamfrd Greater Bridgeprt MHC in Bridgeprt BHcare BHcare Valley Offices in Ansnia (frmerly Birmingham Grup Health Services; aka Valley Mental Health) BHcare Shreline Offices in Branfrd (frmerly Harbr Health Services) Karen Warycha will cver the Ansnia area. Heidi Spaman will cver the Branfrd area. Bridges Cmmunity Supprt System in Milfrd CT Mental Health Center in New Haven Rushfrd Center in Meriden River Valley Services in Middletwn Cmmunity Health Resurces in Windsr Genesis Center in Manchester Nrth Central Cunseling Services in Enfield Heidi Spaman r Karen Warycha will cver Cntinuum f Care: Karen Warycha at r Heidi Spaman at Lretta Ricker at r Lretta Ricker will cver Drthy Fransen at Genesis Center at ext 442 r

15 Inter-Cmmunity Mental Health in East Hartfrd Capitl Regin Mental Health Center in Hartfrd Cmmunity Mental Health Affiliates in New Britain United Services in Dayville Sutheastern MH Authrity in Nrwich Western CT Mental Health Netwrk Greater Waterbury MHA Greater Danbury MHA Nrthwest MHA in Trringtn Lynda Dunlp at Chrysalis Center: Elaine Amat at Elaine Amat will cver until staff hired (if questins, call Jennifer Glick) Call Jennifer Glick Call Jennifer Glick Call Jennifer Glick DMHAS Crisis Services LMHA F.S. Dubis Center Greater Bridgeprt MHC Telephne AM-8PM (24 hurs) Birmingham Grup Health Services Harbr Health Services Bridges CT Mental Health Center (CMHC) r /7714 (9AM- 7PM) (7PM-9AM) River Valley Services (RVS) r Rushfrd Center r Sutheastern MHA (SMHA) United Services (Dayville) (Willimantic) (Clumbia) Capitl Regin Mental Health Center Cmmunity Health Resurces (CHR) Intercmmunity Mental Health Grup Wheeler Clinic Cmmunity Respnse Team r (Genesis & Nrth Central Cunseling) 15

16 Western CT Mental Health Netwrk (Trringtn) (Danbury Hspital Crisis Line) (Waterbury) DMHAS Respite Beds Respite beds are vluntary and may be available as a shrt-term interventin fr a client requiring a 24-hur supprtive envirnment. Respite assists with psychiatric stabilizatin r as transitinal husing t a cmmunity setting, but des nt prvide medical services such as thse fund in a hspital r nursing hme setting. Each respite prgram listed as its wn criteria, including varying length-f-stay. Respite Prgram Descriptin Cntact Infrmatin Greater Bridgeprt MH Center: Transitinal Residential Prgram (TRP) 24/7; vluntary; 20 beds; LOS apprx. 70 days; pen/unlcked unit; persn must be hmeless r at risk fr hmelessness; can participate in wn recvery plan; & have assigned utpatient treatment team. Crretta Williams at Nrwalk Transitinal Residential Prgram (TRP) Rushfrd (Meriden) & River Valley Services (Middletwn) Temprary residential placement lcated at 33 Stevens St., Nrwalk & perated by F.S. DuBis Center; gal is t prvide transitinal husing (30-45 days) fr DMHAS clients transitining back t the cmmunity primarily frm inpatient hspitalizatin; client expected t functin independently. Cllabrative prgram between Rushfrd (10 beds) & RVS (8 beds). Crisis respite beds prvide high intensity service as alternative t hspitalizatin with 24/7 staff. Respite beds prvide less intense service with 24/7 staff. Tm Kinder at Access beds thrugh RVS Mbile Crisis; Mid-State Hspital ED; Rushfrd Acute Care; & RVS Acute Care. RVS cntact: Mbile Crisis Team Rushfrd cntact: Teresa Kriebeck at

17 Cmmunity Mental Health Affiliates (New Britain) Greater New Haven Area: New Haven; Milfrd; Branfrd; Ansnia/Derby; etc. Managed by Cntinuum f Care & Cmmunicare depending n lcatin. Cmmunity Mental Health Resurces (Manchester-Enfield) Waterbury MHA & Waterbury Hspital Jint Prgram: Transitinal Respite Services Trringtn MHA & MHA f CT Jint Prgram: Transitinal Services 4 beds (2 female; 2 male); cannt be hmeless; LOS varies; clients utilizing beds are in crisis in cmmunity; stepping dwn frm inpatient hspitalizatin; r under Jail Diversin. New Haven: 9 high intensity crisis/respite beds with 14-day LOS. 2 beds each lcated in Milfrd; Branfrd; & Ansnia. Clients must be physically manageable; age 18+; & enrlled in CHR services; prvides brief crisis stabilizatin & alternative t hspitalizatin; active prgramming fr individuals wh d nt meet hspital LOC; nt handicap accessible; clients must be able t ambulate withut assistance & climb stairs t shwer. Shrt-term husing fr individuals withut husing due t mental health prblems; 15 beds f which 7 are frensic; LOS varies based n need; perates 24/7. Shrt-term (90-day) care fr peple in recvery having prblems at hme; persn referred must have case manager t facilitate husing needs. Tel: Fax: Cntact Gretchen Elder (Cntinuum f Care) at Cntact Sue Brwn (Cmmunicare) at All beds can be accessed thrugh CMHC; YNHH; & Cmmunicare. 607 Enfield St. Enfield, CT Can be referred 24/7 Lcated n grunds f Waterbury Hspital Cntact Lisa Murray: Litchfield St, Trringtn Cntact Marc Trivella at

18 Sutheast Mental Health Authrity (SMHA) (Nrwich) Sund Cmmunity Services, Inc.: Michael Kerr Respite Prgram (Nrwich) Lcated n grunds f SMHA Mercy Shelter & Husing Crpratin (Operates CRMHC s Respite Prgram cvering Hartfrd; West Hartfrd; Farmingtn; Avn; Simsbury; East Hartfrd; Glastnbury; & Wethersfield) 1 bed Brief Care Unit; persn must be vluntary & meet DMHAS criteria fr services; admissin must take place prir t 9 PM; persn screened by SMHA Mbile Outreach Clinician t determine apprpriateness; LOS 3-5 days. 5 bed shrt-term residential living center fr persns with MI &/r c-ccurring disrders; persn must be vluntary & meet guidelines fr DMHAS services; screening & assessment thrugh SMHA Mbile Outreach; LOS up t 30 days. Fr adults with psychiatric r c-ccurring disrders in mental health crisis presenting t r being referred t general hspital ED; referrals made directly t CRMHC Mbile Crisis in Hartfrd r InterCmmunity Mbile Crisis in East Hartfrd & must include a discharge plan. Cntact SMHA Mbile Outreach: Cntact SMHA Mbile Outreach: beds at 118 Main St., Hartfrd. Cntact CRMHC Mbile Crisis at Cntact InterCmmunity Mbile Crisis at An additinal 4 beds accessed thrugh CRMHC s Managed Service System Divisin. DMHAS Hmeless Services DMHAS prvides services t persns with a serius mental illness, r a c-ccurring mental illness and substance abuse disrder, wh are hmeless. Services include assertive utreach and engagement with clients, and referrals t case management services. 18

19 Cntact Alice Minervin at r alice.minervin@ct.gv Fr a list f emergency hmeless shelters, g t.. CT Hme and Cmmunity-based Services Waivers CT Hme Care Prgram fr Elders* (CHCPE) 1. Age 65+ and Medicaid-eligible. 2. At risk fr nursing hme placement based n 3 r mre critical needs. 3. Cntact DSS Alternate Care Unit: ptin 4. *If nt Medicaid-eligible, may be eligible fr state-funded hme care services. Hme Care Prgram fr Disabled Pilt 1. Ages 18-64; nt Medicaid & cannt have a primary diagnsis f MI. 2. Must have primary diagnsis f degenerative neurlgical cnditin. 3. Has 3 r mre critical needs r 2 critical needs plus 4 r mre cgnitive deficits. 4. Cntact DSS Alternate Care Unit: ptin 4. Acquired Brain Injury (ABI)* 1. Age 18 and lder. 2. Medicaid-eligible. 3. Must have ABI & meet level f care criteria fr nursing hme, including intermediate level, r chrnic disease hspital. 4. Must be able t participate in develpment f a service plan. 5. Cntact DSS at Mental Health Waiver (WISE) 1. Age 22 and ver & Medicaid-eligible 2. Diagnsis f serius & persistent mental illness plus ther criteria. 3. Cntact Visit fr mre infrmatin. Persnal Care Assistant (PCA) 1. Age 18 and lder; Medicaid-eligible. 2. Has chrnic, severe, permanent disability resulting in at least 2 critical needs. 3. Thse with MI, MR, and dementia d nt qualify. 4. Cntact DSS at Dept. f Develpmental Services* 1. Age 18 and lder with diagnsis f MR. 2. Must meet ICF/MR level f care. 3. Must demnstrate a need fr ne r mre f the waiver services. 4. Must be Medicaid-eligible. 5. Cntact DDS eligibility unit at *mre than ne waiver available *If persn has diagnsis f serius mental illness preceding ABI, may be eligible fr DMHAS ABI services. Cntact DMHAS ABI Katie Beckett 1. N age limit, but mst participants are children. 2. Must have severe disability. Mney Fllws the Persn (MFP)* 1. Age 18 and ver; Medicaid-eligible. 2. Persn must be in a nursing hme fr 90 cnsecutive days r mre; wishes t 19

20 3. Medicaid-eligible. be in the cmmunity; & meets criteria 4. Cntact DSS Alternate Care Unit at fr ne f Medicaid waivers ptin Cntact DSS at *Nt a waiver prgram per se. Other Resurces Veterans Administratin Aid & Attendance Benefit 1. Fr vets (r surviving spuses f vets) wh meet service requirements & need help with ADLs; are blind; r a resident f a nursing hme due t physical/mental disability. 2. Incme & asset limits. 3. Cvers hme care services & assisted living services in managed residential cmmunity. 4. Capped by amunt f benefit. 5. Cntact CT Dept. f Veteran s Affairs at NOTE: Fr infrmatin n the West Haven VA Nursing Hme Prgram, cntact Dnna Cramnd at Medicare Hme Care Benefit 1. MD must sign plan f care fr persn wh has need fr at least ne skilled service (intermittent skilled nursing; PT r OT r ST & is hmebund). 2. In additin t nursing & therapies, cvers intermittent HHA when receiving nursing care; medical scial wrk; & DME. 3. N mre than 8 hrs/day r 28 hrs/wk f care unless MD indicates need fr up t 35 hrs & there is a predictable end t need fr mre hrs. 4. Cnsult n eligibility/denials by calling Center fr Medicare Advcacy Statewide Respite Prgram 1. Must be diagnsed with irreversible & deterirating dementia.* 2. Incme & asset limits. 3. Cvers Adult Day Care; HHA; hmemaker; cmpanin; SNF visits &/r ST stays in SNF r ALF. 4. Cst may nt exceed $3,500 per calendar year % c-payment f cst fr each service. 6. Apply thrugh Area Agencies n Aging at *If eligible fr CHCPE, nt eligible fr respite prgram. TIP: Persn may als be eligible fr $500/family annual benefit frm Alzheimer s Assc. CT Chapter s Respite Fund. N age limit fr persn r his/her caregiver. Cntact: Medicaid State Plan Services 1. Physician-rdered as part f a plan f care that is reviewed every 60 days. 2. Begins with referral t cmmunity hme-health agency. 3. Need W-10 if persn discharged frm a facility (NH r hspital). 4. Services: nursing; HHA; Pt; OT; ST; & any supplies, equipment r appliances that are medically necessary. 5. Prir authrizatin required fr mre than 2 nursing visits a week & mre than 14 hurs a week f HHA. 6. Cntact DSS Reginal Offices. 20

21 Other Resurces Aging & Disability Resurce Centers (aka Cmmunity Chices) 1. Independent living philsphy, including self-determinatin. 2. Single-pint f entry system fr access t lng-term care infrmatin, prgrams & services. 3. Area Agencies n Aging partner with Independent Living (IL) Centers. 4. Currently peratinal at 3 sites: Agency n Aging f Suth Central CT at Western CT Area Agency n Aging at Nrth Central Area Agency n Aging at , ext 251. Area Agencies n Aging (AAA) 1. Advcate fr elders. 2. Fund certain cmmunity services, including CHOICES Prgram which prvides infrmatin & assistance n Medicare. 3. Partners with ILs arund ADRCs & MFP agencies, including 3 specified in previus bx, and Suthwestern CT Area n Aging at Senir Resurces Agency n Aging in Eastern CT at Independent Living Centers (ILs) 1. Independent living philsphy, including self-determinatin. 2. Partners with AAA s arund ADRCs & MFP. 3. Advcates fr peple with disabilities; tends t be yunger pp with physical disabilities, but includes peple with mental illness. 4. Lcatins in 5 state regins: Independent Unlimited (Nrth Central CT) at Disabilities Netwrk f Eastern CT at Independent Nrthwest Center f IL f Nrthwest CT at Center fr Disability Rights (West Haven) at Disability Resurce Center f Fairfield Cunty at State Lng-Term Care Ombudsman Prgram 1. Advcates fr residents f nursing hmes, residential care hmes & assisted living facilities. 2. Respnds t & investigates cmplaints brught frward by residents, family members, &/r ther individuals n their behalf. 3. Offers inf & cnsultatin t cnsumers & prviders; mnitrs state & federal laws & regulatins; & makes recmmendatins fr imprvements mbudsman per 3 state regins: Nrthern Regin Intake at Suthern Regin Intake at Western Regin Intake at

22 Nursing Hme Placements/Preadmissin Screening Resident Review (PASRR) PASRR PROCESS fr Persns with Serius Mental Illness This is federal law fr all states. All applicants t Medicaid-certified nursing hmes, regardless f reimbursement surce, must be screened t identify a diagnsis f serius mental illness (SMI) and/r a develpmental disability. If there is a diagnsis, the persn must underg a Level II evaluatin. With sme exceptins, this prcess must be cmpleted prir t nursing hme admissin. In all cases, t be eligible fr nursing hme admissin, r cntinued nursing hme stay, level-f-care criteria must be met. The PASRR screen is initiated thrugh Ascend using a passwrd-prtected web-based system. Tw frms are submitted electrnically: (1) Level I, which identifies whether the persn has an SMI; and (2) Level f Care Determinatin. If the Level I is psitive fr SMI and the persn meets nursing hme level f care criteria, an Ascend evaluatr will meet the persn face-t-face t cnduct a Level II Evaluatin. The Level II is a cmprehensive psychiatric evaluatin t determine if the persn is stable and apprpriate fr nursing hme placement. NOTE: If the persn des nt meet nursing hme level f care criteria, the Level II is usually nt dne. Besides preadmissin screening, nursing facilities must reprt t Ascend when a resident with SMI experiences a change f cnditin/status. A Level II may be required t determine whether the resident requires inpatient psychiatric care prvided in a hspital setting. Ascend tracks thse individuals with SMI wh receive shrt-term apprvals fr nursing hme stay t determine if they cntinue t need nursing hme level f care. Ascend will cmmunicate with the DMHAS Nursing Hme Diversin and Transitin Prgram, and a Nurse Clinician, in designated areas f the state, may fllw an individual during their nursing hme stay. If the individual n lnger meets nursing hme level f care, the nurse cllabrates with the nursing facility scial services staff t transitin the persn t a less restrictive setting. Again, this assistance is nly fr a persn with mental illness (which may include a c-ccurring substance abuse disrder). NOTE: The PASRR prcess is initiated n-line, and yu must be registered with a passwrd. Ascend website: & hit link fr CT WEBSTARS Ascend Supprt Specialist t find ut status f review: ext

23 23