Pathways to Community Living - Program Guidance

The Pathways to Community Living Program (Pathways) is Illinois' Money Follows the Person (MFP) Rebalancing Demonstration. The program began in 2007 with a funding award to 30 states including Illinois, and was recently extended by the Affordable Care Act through September 30, 2016, with an award to an additional 13 states. In Illinois, the program is directed by the Illinois Department of Healthcare and Family Services. The program provides assistance to states to rebalance their long term care systems and assist individuals living in nursing facilities to transition to the community.

The Pathways program is focused on objectives that enable individuals to receive, access, and choose appropriate services in the settings of their choice. It is critical that the individual and those that he/she designates are completely involved and direct the process. This includes agreement to participate in Pathways, and to adhere to a plan of care and potential risks. All plans, including risk identification and the establishment of services, programs, and strategies to mitigate risks are to be person centered and driven.

• Increase the use of home and community based services and supports, rather than institutional long term care services.

• Eliminate barriers that prevent or restrict the flexible use of Medicaid funds to enable individuals to receive support for appropriate and necessary long term services in the setting of their choice.

• Increase the ability of the state Medicaid program to assure continued provision of home and community based long term care services to eligible individuals who chose to transition from an institution to a community setting

• Ensure that a strategy and procedures are in place to provide quality assurance for eligible individuals receiving Medicaid home and community based long term care services and ensure quality improvement.

This initiative is a statewide effort to implement the Illinois General Assembly's charge to promote a balance between home and community based services and institutional long term care. This is often referred to as long term care rebalancing. Partners in the Illinois program include the Illinois Department of Healthcare and Family Services as the lead agency for the program, in collaboration with the Department of Human Services, the Department on Aging, and Illinois Housing Development Authority. There are many other stakeholders involved with Pathways in addition to these state agencies. These include private agencies such as Centers for Independent Living, Community Mental Health Centers and Case Coordination Units, and also the University of Illinois at Chicago College of Nursing.

Illinois has been transitioning individuals through the Pathways program since 2008. As a result, you may already be familiar with transition coordinators and program representatives visiting your facilities. Across Illinois, transition coordinators from Centers for Independent Living, Case Coordination Units, and Mental Health providers are under contract with the state and are responsible for the implementation of this program. Transition coordinators will visit your facility and work to identify and assess individuals who are interested and eligible for the program. To date, the primary referral source for potential candidates has been MDS data through the lead state agency for the program, the Illinois Department of Healthcare and Family Services.

Another significant referral source is nursing home staff. Future outreach initiatives are expected to increase awareness, and you may be asked about Pathways. It is expected that these individuals be referred to the appropriate transition coordinator or local program in your community. Once a referral is made, a transition coordinator will visit the resident and complete an assessment. This includes informing the resident and his/her designee what options are available, and affirming he/she is a good candidate for the program. This process will often take time, and will involve your support and expertise as a long term care professional.

Individuals who have been residing in a nursing home for a minimum of 90 days and are currently enrolled in Medicaid qualify for the Pathways program. Participants must also be interested in moving to the community and are asked to play an active role in the process.

There are several community settings that an individual can move to through the Pathways program. These include homes or apartments owned or leased by the individual or a family member, a community based setting with no more than four unrelated individuals, or a supportive living facility for some individuals. A transition coordinator will work with interested residents to determine appropriate and eligible housing.

The Pathways/MFP program considers nursing home administrators and staff as key partners in the continued implementation of the program. It is expected that the staffs of long term care facilities will welcome and cooperate with transition coordinators. Pathways representatives will be asking for assistance as they interview residents and assist in the development of transition plans. They have a legislative charge and authority to perform these duties.

Not everyone who is referred will be a candidate for transition. Living in the community requires both formal and informal supports, resources, and a desire to make it work. Long term care facilities will continue to have a role in providing medical and non-medical care to persons with physical and mental challenges. The Pathways program is focused on assisting those who are able to successfully live in the community.

For more information, including how to make a referral, please visit us on the Web at:

www.hfs.illinois.gov/medicalprograms/mfp/

HFS 7 (N-4-12)

IOCI0400-12