The Money Follows the Person Demonstration Grant Program (MFP) was passed through Congress as an effort to encourage states to allow the money to follow the person, so those living in nursing homes or other institutions would have the option to live in their own home or in a community-based setting as an alternative.

Indiana is currently one of 31 states who have been awarded grant money under this program. ADVANTAGE Health Solutions Inc. has entered into a collaborative partnership with the Indiana Division of Aging (DOA) to oversee and implement the Money Follows the Person Demonstration Grant Program.

The MFP grant program will continue to allow Indiana to rebalance its long-term care system and encourage development of community-based residential options. Transition target groups have been identified as those who have resided in an institution for three months or longer and are eligible for either the Aged and Disabled Waiver (A/D Waiver) or the Traumatic Brain Injury Waiver (TBI) as well as Medicaid.

Once eligibility for the program has been confirmed, a transition plan of care and cost comparison budget (POC/CCB) will be developed. Participants will be assisted by the Transitional Care Team, consisting of a Transitional Specialist, Transitional Nurse and Outreach Coordinator during the transitional process. The Transitional Specialist will remain in contact with participants through day 365.

To participate in the MFP Program, an individual must:

• Have lived in a nursing facility or hospital for at least three months
• Be Medicaid eligible for one day prior to discharge
• Have health needs that can be met through services available in the community
• Voluntarily consent to participation by signing a consent form
• Be eligible for either the Aged and Disabled Waiver (A/D Waiver) or the Traumatic Brain Injury Waiver (TBI Waiver)
• Move into a qualified residence including:
  • Home owned or leased by the individual or the individual’s family
  • An apartment with a personal lease that includes living, sleeping, bathing, and cooking areas
  • A residence in which no more than four unrelated individuals reside (such as Adult Foster Care)

Once eligibility has been confirmed, the transition plan of care and cost comparison budget (POC/CCB) will be developed. The transition plan details the MFP participant’s community-based needs, including healthcare needs and identifies how those needs are to be addressed when the participant leaves the nursing facility.

A Transitional Care Team, consisting of a Transitional Specialist, Transitional Nurse and Outreach Coordinator, will provide answers to questions about the transition from facility-based care to home and community-based care. Some of the Transitional Care Team’s main duties will include:

• Assessing the health and long-term care needs of each participant.
• Arranging a complete and timely transitional plan of care and cost comparison basis for each participant.
• Completing all necessary paperwork including the pre-transition, discharge, and post-transition checklists.
• Coordinating and collaborating with community-based partners for wrap-around services such as in-house services, nutritious meals, on-demand transportation, and housing.
• Ensuring that community-based needs are met after discharge from the Nursing Facility.
• Educating family or support persons on role during process.
• Maintaining regular case management of MFP participants through day 365.
• Ensuring that each participant has continued access to the necessary supports and services before they are transferred to the HCBS waiver case manager.