Connections to Community Living
Information for Family Care and IRIS Staff
Connections to Community Living is a Department of Health Services,
Division of Long Term Care, initiative to help support choice to live in
the community for individuals currently living in nursing homes and
other institutional settings. The long term care system in Wisconsin has
renewed efforts to assist individuals and families in transitioning to
the least restrictive and most community integrated setting. Aging and
Disability Resource Centers (ADRCs) provide options counseling and, if
eligible for Medical Assistance, enrollment counseling. The process
identifies barriers to relocation and assists in developing a plan to
return home and to the community. For persons eligible for public
benefits, ADRCs assess for functional eligibility using the functional
screen. This information is forwarded to the Managed Care Organization (MCO)/IRIS
consultant agency following enrollment counseling.
MCO teams and IRIS consultants work with the individual and their
families to develop a person-centered transition plan based on
preferences and cost effectiveness, identifying supports already
available to the individual and additional service needs.
For certain relocations, the Department receives an enhanced federal
MA match under the Money Follows the Person (MFP) Demonstration. Persons
eligible are those with longer term stays in the nursing home, (90 days
in the nursing home, not counting Medicare rehabilitation days), who
transition to community integrated settings, such as a home or
apartment, and adult family home of four beds or less, or certain
Residential Care Apartment Complexes (RCACs). ADRCs explain MFP to
eligible residents enrolling in family care/IRIS and obtain informed
consent from those who agree to participate. Prior to transition, MCOs/IRIS
consultants administer a Quality of Life survey and report relocation
information to the MFP demonstration staff.
Some counties have been identified as areas with large numbers of
Medicaid funded nursing home residents (PDF
46 KB). Community
Living Specialists (CLSs) are assigned to these areas to assist the
ADRCs with outreach and information to nursing home residents and
nursing home staff. Like the ADRCs, CLSs meet with persons who answer
yes to the nursing home MDS assessment Section Q “Do you want to talk to
someone about the possibility of returning to the community?” They help
families and other supports identify issues and concerns that affect
health and safety and may assist in meeting with care teams and the
person-centered planning process. They may supplement the work of the
care teams/consultants as requested to ensure a successful transition.
As part of the outreach to nursing home residents, ADRCs and the CLSs
give information to nursing home residents who may not know that
community living is an option. They discuss community resources and
housing options with persons who no longer have a home to return to.
They meet with spouses and other family members to discuss caregiving
options and other available supports so that a person can return home.
They act as an advocate on behalf of the individual to ensure choice and
preference, and to live as independent as possible. CLSs also meet with
new admissions to support discharge plans already in place and provide
resource information as needed.
Connections to Community Living is a program supported through the
Demonstration Grant. CLSs may assist ADRCs in discussing MFP and
obtaining informed consent to participate, and care managers in
administering the MFP Quality of Life survey, as requested.
Links to helpful resources:
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Last Revised: April 11, 2013