Moving Back Into the Community: Experiences of a Pilot Program in Relocating Nursing Facility Residents with Behavioral Health Disorders Into the Community

Purpose: Money Follows the Person (MFP) is a federally-funded national demonstration program that helps Medicaid enrollees transition from institutional- to community-based care. In 2008, Texas initiated a Behavioral Health Pilot (BHP) project to investigate whether individuals eligible for MFP who had mental health and/or substance abuse problems could successfully live in the community if offered appropriate targeted supports. Questions addressed in this presentation are:

How many BHP participants stay in the community? Are participants satisfied with BHP services? What individual or situational characteristics predict program success? and Do participants show improvement on quantitative measures of functioning during their year in the program?

Methods: Participants include individuals from two large Texas urban areas who have resided in a nursing facility for a minimum of three months, have expressed a desire to live independently and have a diagnosed mental health or substance abuse disorder. Participants were offered up to six months of services prior to community move-out and one year of services in the community. BHP services included weekly visits by a case manager/therapist who offered specialized Cognitive Adaptation Training, a psychosocial treatment assisting participants with activities of daily living, and substance abuse treatment. In addition, participants receive ongoing home and community-based services (HCBS) through their Medicaid HMO.

Semi-structured interviews were conducted with current and “graduate” participants along with quarterly quantitative assessments of participants (Multnomah Community Ability Scale [MCAS] and the Social and Occupational Functioning Scale [SOFAS]). Twenty four participants were qualitatively interviewed and quantitative assessments from 121 participants were analyzed.  Eighteen key informants (e.g., staff) were also interviewed.

Results: Overall, 87% of the individuals served since the beginning of the Pilot have successfully maintained community independence. Interview findings show that the vast majority were pleased to be out of the nursing facility due to increased independence and privacy, and living in a happier environment.

While both participant characteristics (younger age, cognitive competence, family and social support, history of successful independent living prior to institutionalization) and well-coordinated services helped predict success in the program, key informants remarked that the most important predictors were attitudinal: a positive and optimistic outlook, motivation, determination, goals and a strong desire for independence. 

Quantitative analyses showed participants made significant improvements in targeted functional outcomes on the MCAS total score (p<.0001) and three subscales of the MCAS, including Interference with Functioning (p<.01), Adjustment to Living (p<.0001) and Behavioral Problems (p<.0001). Significant improvement was also seen on the SOFAS (p<.001).

Implications: Findings suggest that BHP services can help people with behavioral health disorders transition successfully from nursing homes to the community and maintain independence with satisfactory quality of life.  Transitioning persons to the community has benefits both for the social system (reduced costs) and for individuals (quality of life), and these services should be integrated into the Medicaid-funded Long-Term Services and Supports system. Further analysis will reveal whether time-limited Pilot services, in conjunction with ongoing Medicaid HCBS services, are sufficient to maintain long-term community tenure.