Key Partners

·        Kansas Department of Aging and Disability Services (state unit on aging (SUA))

·        Kansas Association of Area Agencies on Aging and Disability

·        Central Plains Area Agency on Aging

·        Southwest Kansas Area Agency on Aging

·        Topeka Independent Living Resource Center (Center for Independent Living)

·        The Independent Living Resource Center (Center for Independent Living)

·        Assistive Technology for Kansas (State Assistive Technology program)

Care Transitions Support

The Kansas No Wrong Door (NWD) System utilized COVID-19 grant funds to enhance nursing facility care transitions. The Kansas Department of Aging and Disability Services (KDADS) partnered with the Aging and Disability Resource Center (ADRC) of Wichita, a partnership between the Central Plains Area Agency on Aging (AAA), Topeka Independent Living Resource Center, and the Independent Living Resource Center in Wichita. Other partners included Assistive Technology for Kansas and the Kansas Association of Area Agencies on Aging and Disability (k4ad). Southwest Kansas AAA served as the fiscal agent, with K4ad assistance on billing.

The program received referrals from individuals and their family and/or friends, nursing facilities, managed care organizations and other community-based organizations. To qualify, individuals had to have at least one informal support or caregiver and the financial means to cover housing, groceries and utilities.

K4ad administered grants to the local partners, ensured processing of invoices, assisted with the resolution of issues, and tracked outcomes. The AAA and the CILs provided person-centered options counseling at the nursing home and information and referral including social determinants of health and social isolation screening.  They also provided care management by assisting in searches for housing, helping with the purchase of household items, identifying contractors to do home modifications, and providing other direct assistance to individuals transitioning. Additional supports included applying for Medicaid waiver services and Programs of All-inclusive Care for the Elderly (PACE), obtaining Medicare physician’s orders for home health, filling prescriptions, and delivering durable medical equipment and groceries.  Once an individual transitioned to the community, the care managers at the ADRC conducted follow-up and ensured supports continued.

Assistive Technology for Kansas provided electronic devices and training, technical assistance on durable medical equipment and adaptive devices, and the purchase of internet services for a year for participants.

Lessons Learned (reported by SUA)

·        Showcased the purpose and value of partnerships within the NWD System to facilitate successful transitions.

·        Confirmed that both older adults (age 60 and older) and people with disabilities prefer living in the community.

·        Demonstrated that low-need individuals unnecessarily live in nursing facilities within the state.

·        Learned that durable medical equipment can be the only item that is needed for a person to transition and remain safely in their home.

 

Outcomes (reported by SUA)

These outcomes were reported by KDADS. Individuals who were supported in transitions were asked to complete a survey developed by KDADS’ contractor.

·        55 individuals transitioned, including HCBS waiver participants and non-participants

·        98 percent of individuals supported said they would not have had the information needed to transition without the assistance 

·        100 percent reported that they continue to use the ramps, durable medical equipment and technology provided by the program

 

Implications

While Kansas does not have funding to continue the transition program, they are looking at how they can take lessons learned from this program to  accelerate transitions occurring through other means. In addition, the partnerships formed led to the development of a new ADRC webpage: https://wehelpkansas.com/