New York Association on Independent Living

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Money Follows the Person Peer Outreach and Referral Program

Lindsay Miller, Executive Director
November 30, 2015

Open Doors

New York Association on Independent Living (NYAIL)

  • Statewide, not-for-profit membership association of Independent Living Centers.
  • ILCs are unique disability-led, cross-disability, locally administered not-for-profit organizations, providing advocacy and supports to assist people with disabilities of all ages to live independently and fully integrated in their communities.

Independent Living in New York

  • ILCs have been transitioning and diverting people from institutions for more than 20 years.
  • ILCs are RRDCs for NHTD/TBI waivers as well as providers of services.
  • ILCs are fiscal intermediaries for CDPAS program.
  • Six ILCs are regional lead for Ombudsman Program.

NYAIL Money Follows the Person

  • Prior focus of MFP was Identification and Outreach.
  • New focus on transition and peer services.
  • NYAIL initiated MFP January 2015
  • Two components:
    • Peer Outreach and Referral (Part A)
    • Transition Center (Part B)

Transition Center Project

  • Goal: Identify potential participants in nursing facilities, developmental centers and intermediate care facilities and facilitate successful transitions.

Open Doors Transition Center

Transition Center Structure

  • 9 Regional Lead ILCs
    • Transition Coordinator/Liaison
    • Transition Specialist(s)
  • 14 Auxiliaries ILCs
    • Transition Specialist(s)
  • NYAIL Staff
    • Project Director
    • Statewide Transition Specialist
    • 2 Nurses
    • Social Worker

Transition Specialist Role

  • DOH programs - NHTD/TBI/MLTC
    • Work collaboratively with NHDP and SC to resolve barriers to transition
    • Identification of Community Resources
      • ILC staff in all areas of state
    • Community Preparedness Education
    • Follow-up after transition
      • QoL Surveys

Peer Outreach and Referral Program:

  • Goal: Provide peer support to individuals and/or their families concerned about transitioning.

Open Doors Transition Center

Peers: Who qualifies?

  • Peers will approximate the characteristics of the individuals (age, physical and/or developmental disability);
  • When possible, peers will have transitioned from an institutionalized setting into the community.

Peer Services Structure:

  • Fee-for-service model: NYAIL has entered into MOUs with ILCs to supply paid peers.
  • Twenty four participating; each committed to supplying a minimum of two paid peers.
    • Peers are paid between $12 and $20 per hour.
  • Peers are available in every county.
  • Over 50 peers with physical disabilities and over 25 peers with developmental disabilities.

Peer Training:

  • All peers are required to complete an eight hour web-based training within two months of becoming a peer. Training themes include:
    • Program rules and regulations
    • Overview of peer support
    • Communication and active listening
    • Disability etiquette
    • Cultural, developmental and linguistic competence
    • History of disability rights and independent living
  • Continued learning opportunities to support peers and prevent burnout. In person and virtual meetings.

Peer Services:

  • Transition Specialists will offer peer services to all MFP participants.
  • Peers will conduct a face-to-face meeting within 10 days of referral or document barriers to meeting.
  • After transitioning to a home or community based setting, the individual can continue to receive peer services.

The Peer Visit:

  • Peers meet face-to-face with individuals to discuss the possibility of transition, help address any barriers, share personal experiences, etc.
  • At the end of the first visit, peers will request the individual complete a brief satisfaction survey.
  • An individual can request an additional visit with a peer, and, if approved by NYAIL, the peer can spend a pre-approved number of hours with the individual.

Peer Outreach:

  • Peers are paid for organizational outreach.
  • The "Speakers´ Bureau" approach is popular among centers. Two or three peers visit a nursing facility and share their transition stories.
  • Peers also partner with Transition Specialists and other ILC staff when visiting long term care councils, ombudspersons, etc.
  • Peers have presented at conference, long term care councils, resident councils, ombudspersons, MFP Stakeholder meetings, senior centers, area agencies on aging and other locations identified by the local centers.
  • Statewide marketing campaign in development.

Peer Services to Date

Target Population Peer Matching (as of 11/25/2015)
ID/DD: Intellectual or Developmental Disability (OPWDD) 45
Dual Diagnosis: TBI + Mental Illness 1
TBI: Traumatic Brain Injury (TBI Waiver) 12
ELD: Elderly, over 65 (NHTD) 37
PD: Physical Disability under 65 (NHTD) 57
Unknown Population 14 (mostly because of referrals generated by peers, so target population has not been verified by a Transition Specialist)
Total 166

Staff Contact Information:

  • Lindsay Miller, Executive Director
  • Suzanne de Beaumont, Transition Center Project Director
  • Zach Garafalo, Peer Outreach and Referral Program Director
  • Visit or call 1-844-545-7108 to learn more about the Open Doors MFP projects and the New York Association on Independent Living.

Open Doors

New York Association on Independent Living 1.518.465.4650

This document was developed under grant CFDA 93.791 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the federal government.