A seven-county Money Follows the Person Federal Demonstration Project is based at Putnam Independent Living Services and its Westchester counterpart, Westchester Independent Living Center. The program focuses on providing objective information to nursing home residents who are considering a move into the community.
Donna Ponessa, RN, MPA, is the project coordinator. With about 90 nursing homes in the Lower Hudson Valley Region, Ponessa and her team spend a lot of time on the road. “Once a nursing home resident expresses a wish to be discharged an appointment is scheduled to meet with him or her” Ponessa explained “we meet with the resident to learn about what they feel they need to successfully transition out of the facility and to provide them with information on the community based services that may be available to them.”
The person’s family and social worker are part of the process and are involved from the early stages. Ponessa points out that family support is a big factor in the person’s success. But in some cases the family can underestimate the ability of their family member and find it hard to accept they can live outside the nursing home.
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The program receives referrals from many sources including the individuals wanting to leave nursing homes for their own homes; from family and friends; the Department of Health; and nursing homes. With assistance of Money Follows the Person (MFP), 103 people in the Lower Hudson Valley Region have been able to transition out of nursing homes to community living in the last 18 months.
Some cases stand out for Ponessa. She mentions the man who had a debilitating stroke. He was a large man, quite tall, and had significant disabilities caused by the stroke. The nursing home where he lived was very concerned about his desire to leave. He did however have a very supportive family who felt they could provide the help he needed. Ultimately he was able to return home, and with the help of home care services, other community based services, and assistance from his family, his quality of life improved greatly.
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In addition to conducting outreach to nursing homes, and receiving lists from the state regarding residents with the potential for discharge, Ponessa actively reaches out to the community to provide information. She, and her team, make presentations at senior centers and community meetings, and provide continuing education and ombudsman training.
To keep current on industry changes and community based services the MFP team sits on local and regional long term care councils. Networking though the councils helps them to know more about the availability and usability of services. Recent changes in Medicare/Medicaid have made this especially challenging and Ponessa is looking forward to the implementation of more comprehensive legislation that may have the potential to simplify the process of transitioning an individual from a nursing home.
Disabled herself, Ponessa is familiar with how easily the ability of a person with a disability can be underestimated. She knows though that with the right supports in place many people have more opportunities for success. For example there might be transportation difficulties that can be solved by using public or para transit. In many locations older adults, aged 55 and older, can access congregate and home delivered meals and recreation programs through the Office for the Aging. Day programs and home care options might be needed or help with making a home accessible. Vocational rehabilitation programs and local programs can be explored.
Two of the biggest barricades to successful placements outside the nursing home are particularly challenging. There is a lack of affordable, accessible housing. Modifications to existing housing stock can be costly and new housing isn’t often built according to the standards of universal design, a philosophy that designs accessibility into new construction. In many municipalities Section 8 voucher applications are not being accepted, and the waiting lists are closed. In areas where applications are being accepted the lists are long and waiting for a voucher can take years. Vacancies in senior housing fill up quickly.
The need for home health aides is critical. They can potentially determine the success or failure of a move from a nursing home. If a person requires home care services and there is no aide available it is a huge barrier for them to overcome in order to return to the community. Aides can have difficulty with transportation in the less populated areas of the Lower Hudson Region with limited public transit. Salaries are low and the work is challenging.
Ponessa is positive. She invites family and individuals to call her to talk about the feasibility of an individual leaving a long term nursing facility. Funded through the New York State Department of Health, MFP services are provided at no charge to the individual. And, as Ponessa points out, it’s a voluntary program and there are no obligations if a person changes her or his mind.
Donna Ponessa can be contacted at Westchester Independent Living Center in White Plains at 914.682.3926 or at Putnam Independent Living Services, in Carmel at 845.228.7457 or 866.933.5390 (VP/TTY).
