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PROJECT HOME

PROJECT HOME. OVERVIEW. Demonstration Project, 2005-2009 Implemented by Loretto with funding support from: NYS DOH Community Health Foundation of Western and Central New York. PURPOSE.

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PROJECT HOME

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  1. PROJECT HOME

  2. OVERVIEW • Demonstration Project, 2005-2009 • Implemented by Loretto with funding support from: • NYS DOH • Community Health Foundation of Western and Central New York

  3. PURPOSE • Respond to public policy and desires of an aging population to receive care in home and community based settings • Demonstrate cost savings at the local and State level • anticipated lower cost of care for individuals who use home and community based care over institutional care • Identify barriers preventing successful discharges from SNFs

  4. COMPONENTS • Discharge Planning • Implemented by Loretto • Workforce Development • Sub-contracted with 1199 Training and Upgrade Fund (TUF) and PHI • Evaluation (Discharge Planning) • Cornell Institute for Translational Research on Aging (CITRA)

  5. DISCHARGE PLANNING COMPONENT • Create an early identification and comprehensive referral and discharge planning system for hospitalized individuals identified as being in need of nursing home care • Assist area nursing homes in effective discharge planning for residents able to and desiring to live in non-institutional settings • Work with individuals whose physical or psychological health issues, housing, financial, or other needs make it challenging to create a discharge plan.

  6. DISCHARGE PLANNING • Plan: place 150 individuals into home and community based settings, who otherwise would likely have remained in a skilled nursing facility. • Total of 455 referrals were made • resulting in 130 enrollments • 74 discharge plans were implemented

  7. FIELD FINDINGS • Difficulty of early identification: • Referrals: 96% from nursing homes, 4% hospitals • Original design - majority of referrals from hospitals • early identification • pro-active efforts before available resources eroded or living arrangements lost • Became impossible to secure a meaningful number of referrals from hospitals • Perhaps due to the intense pressure to discharge patients quickly once conditions stabilize

  8. FIELD FINDINGS • Potential for assisting younger population • Enrolled 130 of 455 referrals • Reasons for not-enrolling: • Under 65 • Out of Onondaga County • Declined

  9. FIELD FINDINGS • Needed but not readily available services for discharge success: • case management • services that assisted with banking, grocery shopping, housekeeping, household repair, prescription coordination • subsidized housing facilities or rental assistance programs - waiting lists limited their availability

  10. EVALUATION • CITRA

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