The Community Care Settings Pilot: Ensuring A Smooth Transition Back Into Community

Editor’s note: The John A. Hartford Foundation, the Administration for Community Living and The SCAN Foundation fund the Aging and Disability Business Institute, led by the National Association of Area Agencies on Aging (n4a). The mission of the Aging and Disability Business Institute is to build and strengthen partnerships between aging and disability community-based organizations (CBO) and the health­­care system. As partners in the Aging and Disability Business Institute, ASA and n4a are collaborating on a series of six articles and case studies in Aging Today that highlight the Age-Friendly Health Systems initiative.

This past July, the Aging and Disability Business Institute (ADBI) presented San Francisco’s Institute on Aging (IOA) with The John A. Hartford Foundation 2019 Business Innovation Award. The IOA received this award for its pioneering work in helping older adults and individuals with disabilities to transition from institutional settings into living independently in the community.

Specifically, the award lauds the Community Care Settings Program, celebrating IOA’s person-centered approach to ensuring that individuals have the supports they need to live well in community. The IOA has helped approximately 50 people per year to make these transitions, and the Community Care Settings Program enjoys a 93 percent placement success rate, which also translates into signifi­cant cost-savings. Versions of the pilot program are now being replicated in other California counties.

Dustin Harper, IOA’s chief strategy officer, says that the program, run since 2014 as a collabora­tion with Brilliant Corners (formerly West Bay Housing) and the Health Plan of San Mateo (a county-based Medi-Cal and Medicare health plan in California), has “created a different sense of what’s possible regarding supporting alternatives to long term care.” The pilot is based on a three-pronged approach—intensive care management, housing services and enhanced support servic­es—and targets long-term-care residents who would like to return to the community as well as individuals at imminent risk of institutionalization.

Looking to the future, Harper adds, “There’s now a blueprint for a true exit pathway out of any nursing home in California.” California policymakers seem to have taken notice; the recently re­leased Medi-Cal Healthier California for All initiative includes proposed new benefit structures, which have the potential to develop similar models statewide.

The Backstory on Success

In describing the pilot’s genesis, Harper says that in 2013, the Health Plan of San Mateo was plan­ning, in stages, for moving into the Cal MediConnect program, which is part of a federal demon­stration project to create one integrated healthcare plan for members enrolled in both Medicare and Medi-Cal (referred to nationally as Medicare-Medicaid Plans). Concurrently, one of San Ma­teo County’s largest skilled nursing facilities was anticipated to close, furthering an already sig­nificant local nursing home bed shortage.

The Health Plan of San Mateo released a Request for Proposal in 2014 for the Community Care Settings Program. Institute on Aging and Brilliant Corners submitted a joint proposal based on similar work the organizations had been doing in San Francisco related to transitioning individu­als out of the large county-run skilled nursing home.

In both projects, Harper said, “There has been a need to shift mindsets and historical clinical pathways around managing complex needs in the community.” Increasing recognition of the value of addressing social determinants of health, coupled with policy changes that better align financial incentives have combined to create opportunity for new, sustainable models that promote com­munity living.

“If you look at California’s nursing home population, most stakeholders agree that about 10 to 20 percent of the people in nursing homes don’t require that level of care,” says Harper. “What those individuals have in common is their desire and ability to live in a community setting rather than an institution. Beyond that, there are a wide range of barriers and needs to be addressed to achieve successful placements.

“A 30-year-old returning to the community as an individual with a disability for the first time is looking for a much different environment and set of services than an 80-year-old who is primarily in a nursing home due to cognitive impairment,” he adds. As a result, the Community Care Settings Program develops and facilitates multiple pathways back into the community.

Traditionally, says Harper, a nursing home discharge planner is responsible for put­ting together a care plan for an individual when he or she leaves the nursing home. However, if that plan starts to fall apart, or is put off due to a referral delay, there of­ten isn’t a care management entity charged with successfully implementing the discharge plan. IOA has found that involving a care manager early, and keeping them involved for 
9 to 12 months ensures a smoother transition and leads to higher placement success rates. Beyond supporting the individual, the IOA support also reassures the housing community that the indi­viduals will receive the services needed to be successful.

Lauding Demonstrated Success

On receiving the Business Innovation Award from the ADBI and The John A. Hartford Founda­tion, Harper says, “It means a lot to us to have demonstrated success with a model that both in­creases available resources for low-income, vulnerable individuals and saves taxpayer money. We are particularly grateful to organizations like Health Plan of San Mateo and the San Francisco Department of Disability and Aging Services for their belief in this model and providing an envi­ronment to pilot new approaches.

“Both organizations pushed to make access to community living more of a consistent best prac­tice—they deserve a lot of credit for that.”