Home Reintegration

Reintegration

Many consumers can now live independently through the Community Reintegration Program and Money Follows the Person program.  These programs are set up for consumer’s 59 and under who are living in a nursing home and have no home to return to and need assistance getting started again on their own.  These programs are intended to be a onetime only process to help with the initial set up of basic living arrangements, as well as linkages to services needed to live independently.  With the help of a personal assistant, who assists with daily living tasks, these consumers are able to live in the community very successfully.  If you know of anyone who might need these services, please contact the Reintegration Specialist.

Money Follows the Person

In comparing institutions to community living, Independent Living advocates have pointed out the cost of nursing homes is much more than the cost of supports for community living.   The question has become “if people want to move into the community, why can’t  the money spent previously on institutions follow the person with a disability into the community.  This would finance supports that are needed for them to live in the more dignified, enjoyable and economical setting.  The concept of Money Follows the Person would increase the community capacity to provide those supports and enable more people to de-institutionalize.

Money Follows the Person is a Federal demonstration grant that began in 2007, to assist individuals in nursing homes for three months or longer to transition back into the community.  This grant runs through 2016 with additional federal funds allocated to the program.  Reform legislation gives the state the opportunity to make some adjustments in the project and work toward increasing transition.

Eligibility:

  • Between the ages of 18 and 59, has a severe disability that will last for 12 months or the duration of life.
  • Needs long term care as established by the Determination of Need (DON)
  • Has physician’s approval of plan of care
  • Has no more than $17,500 in non-exempt assets
  • Does not require in-home services that are expected to cost more than institutional care
  • Is open to recommendation of staff regarding referrals for other services and demonstrates a willingness to follow through
  • Is able to follow all action steps to complete reintegration
  • Is able to demonstrate initiative in meeting goals
  • Is a citizen or legal alien
  • AND must meet one of the following:

    1. CRP  Community Reintegration ProgramHas resided in qualified institution Has applied for Medicaid benefits
    2. MFP  Money Follows the Person Pilot Project
      Has resided in qualified institution for three months or longer
      Has received Medicaid a minimum of 30 days

Our Partners in Reintegration:

Partners in the MFP program are
Division of Rehabilitation Services
(website http://www.dhs.state.il.us/page.aspx?item=29764
Health and Family Services
(website http://www.hfs.illinois.gov)

 

How Referrals are Made

Referrals to PACE are made by the Social Worker at the nursing home, the consumer themselves or a family member.  Then Reintegration candidates are seen in the nursing facility by the PACE Reintegration Specialist who will do an initial assessment to determine if they are appropriate for the program.

The PACE Reintegration Specialist will be working on these steps to facilitate an accessible and well thought out move.

  • Process of Preparing to move
  • Set up appointment for consumer and facilitator to meet.
  • Gather medical documents from nursing home file
  • Meet with consumer to determine eligibility, needs and complete initial paperwork
  • Get physician’s approval documented
  • Send acquired paperwork to Department of Rehabilitation Services
  • Obtain approval for move from Department of Rehabilitation Services
  • Schedule staffing to discuss reintegration plan
  • Start finding housing and any necessary home modifications or adaptations such as ramp
  • Gather adaptive equipment
  • Arrange personal assistance and backup
  • Pay first and last month’s rent and security deposit
  • Shop for household goods and furniture
  • Arrange delivery
  • Arrange help with physical moving
  • Start up utilities
  • Shop for startup groceries
  • Provide community resources such as equipment repair and pharmacy, also coaching on who to call when
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