Nursing Facility Case Study

Client Characteristics

  • Name: Milton Jones
  • Sex: Male
  • Age: 54
  • Diagnoses: Broken Back with Paralysis of Lower Extremities
  • Date of Nursing Facility Admission: January 20, 2005
  • Legal Status: Legally Competent Adult
  • Current Residence: STU Nursing Care, a 256 bed large nursing facility located in Amarillo, Texas


Milton is 54 years-old and resided in a nursing facility for nearly two years. Milton had been a long-haul truck driver for about ten years when he had an accident on an interstate highway during a winter blizzard in the Texas Panhandle. He sustained a broken back with paralysis in the lower extremities, and after a six week stay in a rehabilitation hospital, he was transferred to a nursing facility in Amarillo.

Before the accident, Milton rented a home in a small town outside of Marble Falls, Texas, a city approximately 600 miles from Amarillo. Milton had no immediate family and was also estranged from his ex-wife. Before the accident, he had monthly phone calls with his 22-year-old son who lived in Dallas.

After about eighteen months in the nursing facility, Milton felt he was too young to be in a nursing facility and desperately wanted return to Marble Falls or at least live closer to the community where his son could visit him more frequently.

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Learning about Community Options

When Milton first arrived at the nursing facility in Amarillo, he remembered hearing from a DADS eligibility worker about some community options that may be available. However, at that point, he had been in pain, and because he thought he was going to receive rehabilitation services in the nursing facility and then leave, he did not pay much attention. So after a year and a half, he started asking the nursing facility staff about leaving. This seemed difficult because he appeared to need 24-hour care and he could not walk or transfer himself very well.

One of his friends in the nursing facility who was getting ready to move suggested that Milton speak with the Ombudsman from the Area Agency on Aging (AAA) and the relocation specialist, both of whom frequently visited the nursing facility. He had seen the Ombudsman talking with other residents and asked to speak with him. The Ombudsman gave Milton a brochure called “Money Follows the Person to Community Living” and contact information for the local relocation specialist, who is contracted by the state to specifically assist nursing facility residents, who want to relocate, and the Department of Aging and Disability Services (DADS) case manager.

In Texas, consumers are informed about community options when they apply for Medicaid. Nursing facility social workers, AAA Ombudsman, and relocation specialists are direct sources of information about services in the community.


Assessment for Transition Services

Relocation specialists routinely check the Minimum Data Set (MDS) Q1A information provided to them by DADS to see who has expressed an interest in moving to the community. In this case, the referral came from the AAA Ombudsman’s Office. Within a week of this referral, the relocation specialist went to the nursing facility to meet with Milton to verify his request, discuss his relocation needs, and conduct a relocation assessment. The relocation specialist also provided Milton with a brief description of the types of 1915(c) waiver services available and told him that a DADS case manager would provide more detailed information when the two met in the near future; the relocation specialist helped to facilitate that meeting.

The relocation specialist then began talking with Milton about the types of transition support he might want during and after his transition to the community. The relocation specialist said that they could re-visit the transition assessment as frequently as needed after relocation. The relocation specialist told Milton that this ongoing process was intended to support him through the transition; however, Milton would be making the decisions. He could use as much or as little relocation support as he wanted.—?

The relocation assessment identifies the following information:§

  • Personal data
  • Medical conditions and professional care needs such as the need for physical therapy
  • Previous home care arrangements (if any)
  • Housing and neighborhood preferences
  • Financial situation which would be important in securing housing
  • Family supports that can be provided
  • Transportation needs
  • Public and private supports needed
  • Assistive technology needs

During the relocation assessment, Milton requested to be able to live in a place where his son could visit and stay with him for several days. Milton also requested to be close to a grocery store, a bookstore because he enjoys reading, and would need transportation to medical appointments. The relocation specialist assisted Milton with contacting the local DADS office so he could request community-based services and begin the enrollment process.

A couple of days later, the DADS case worker contacted Milton to schedule a visit at the nursing facility to begin the application process for community-based services. The case manager discussed program guidelines, medical and financial eligibility criteria, and services for the various programs that were available to Milton. The case manager also informed Milton that he had several options for directing his services. He could select the consumer directed services (CDS) option where he is the employer of his attendant and could set the wages for his attendant within the rate set by the state. If he selected CDS, he would need to work with a financial management agency. Alternatively, Milton could select an option called the Service Responsibility Option (SRO) where he could select, train, and supervise his attendant but the direct service (home health) agency remained the employer of record. The final option discussed with Milton was one in which he could rely on the home health agency to find his attendant. The case manager discussed the advantages and disadvantages of each option. While Milton liked the idea of hiring his own attendant, he decided to start with the agency option and then check into CDS later.

Milton chose the Community-based Alternatives (CBA) program as it offered everything he needed including nursing services, personal attendant services, minor home modification, adaptive aids, transportation to medical appointments, and professional therapies like physical therapy and occupation therapy (see Glossary).§

The case manager then provided Milton with a list of providers and asked him to choose a home health agency to complete the rest of the assessment. She told Milton that the next step was to meet with the home health agency and that she would fax the referral to the home health agency he selected so that they could complete the Level of Care Assessment for community services.

Milton met with his chosen home health agency to complete his Level of Care Assessment for community-based services and to develop his service plan. Three activities then had to occur: (1) the home health agency had to accept Milton’s referral; (2) the DADS case manager had to verify that he had met all the eligibility criteria including medical necessity, financial eligibility, medical effective date, and (3) the services had to be identified in the service plan. Once these activities were accomplished, the DADS case manager notified Milton, the relocation specialist and the social worker at the nursing facility to finalize discharge plans and arrange transportation to Marble Falls.


Service Coordination

Prior to the move, Milton met with his DADS case manager, relocation specialist and others to develop a plan to ensure the success of his transition. Together they revisited Milton’s goals and objectives for living in the community as well as the respective responsibilities of Milton, his community support and the staff supporting his transition.

Because of Milton’s extensive functional and support needs, the DADS case manager also let Milton know that there are a number of community-based organizations that might help him resolve problems that might arise during the transition and throughout his enrollment in the CBA program. This additional community support comes through the regional Community Transition Teams (Team) that DADS originally established as part of a 2002 CMS Real Choice grant.

There is one Team in each of the DADS regions and they are comprised of public-private partners with representatives from: DADS, consumers, AAAs, Adult Protective Services, advocacy groups, housing organizations, long term services and supports providers, nursing facility staff, AAA Ombudsman, Mental Retardation Authorities, Mental Health Authorities, and other not-for-profit and for-profit organizations. The Team meets monthly to address specific barriers that prevent a nursing facility resident from relocating into the community, to ensure continued success, and promote effective transitions from nursing facilities back to the community. The Team also addresses systematic barriers within their communities.

One of the major barriers to Milton’s relocation was his lack of community housing. In Texas, there are three sources of housing assistance that can help with making monthly rent payments: HOME rental vouchers; Tenant Based Rental Assistance (TBRA); and the Texas’ Housing Voucher Program (HVP), which provides Project Access vouchers to persons leaving nursing facility settings. Each of these sources of housing assistance is from the U.S. Department of Housing and Urban Development to the state housing finance agency and local public housing authorities. Because of limited housing resources, relocation contractors help individuals fill out the paperwork for placement on waiting lists for every type of housing assistance program.

Because of the limited resources for housing assistance, it took several months to find housing to meet Milton’s preference for enough space so his son could visit and that was also in the para-transit service area. Also, he did not realize that it would take so long to find a place to live that could accommodate his physical disabilities and that he could afford. Many of the housing options were not wheelchair accessible and did not have the kind of shower he needed. Everything was on hold until Milton could find a place to live. During this time, his relocation specialist visited him every few weeks to give Milton an update on the housing situation.

While the relocation specialist was working to secure housing for Milton, the MFP Demonstration Project Director was meeting with the local public housing authority (PHA) to explain the Demonstration and need for dedicated housing vouchers for nursing facility residents who wanted to relocate. The Project Director provided training and educational materials on Medicaid and the availability of long term services and supports. He also discussed the opportunities provided through the Demonstration and how the Demonstration could benefits clients of the PHA. The state agency and the PHA signed a Memorandum of Understanding (MOU) detailing how the state agencies and the PHA would work together and the commitment of the PHA to dedicate ten vouchers specifically for Demonstration participants.

After three months, the relocation contractor was able to obtain one of these ten new tenant-based rental assistance vouchers for Milton.

Texas also offers two types of community transition supports to individuals who reside in nursing facilities and want to receive their long-term services and supports in a community setting. These services can be used for setting up a household in the community. Transitional Assistance Services (TAS) is provided under the Medicaid 1915(c) waiver and will provide one-time start-up funds of up to $2500 to help an individual establish a community residence. Start-up funds available through TAS are not allowed for individuals relocating to Adult Foster Care or Assisted Living facilities. The start-up funds can be used for expenses directly related to moving, including but not limited to paying for moving expenses; housing deposits; utility deposits; cooking utensils; other moving-related expenses and household start-up costs. §

Also, DADS administers a general revenue program named Transition to Life in the Community (TLC). The TLC program can provide funds for expenses that are not covered by Medicaid through TAS or other long-term services programs.§ TLC funding is considered a wrap-around activity to TAS.

Milton, the DADS case manager, the home health agency, and the relocation specialist, determined a discharge date from the nursing facility once the residence was established. During the intervening time, the DADS case manager helped Milton identify any household items, such as furniture, dishes, towels and bedding, and/or security deposits that he required to be bought through TAS/TLC. Finally, even though his new apartment was accessible, Milton needed to have a special shower chair before he could move; the home health agency provided the chair.



On the day of discharge and relocation, Milton’s relocation specialist met him when he arrived at the apartment. Milton noticed that the kitchen was stocked with groceries and he had a few sets of clothing in his bedroom. The DADS case manager and home health agency made sure that Milton’s personal assistance worker reported to work at the same time Milton showed up at his new apartment.

Milton initially had difficulty with his nurse making visits on a regular basis. §Concerns like this made him wonder if he could survive alone in his apartment. He discussed this with his DADS case manager, and the home health agency was able to meet his nursing needs on a regular basis. Before leaving, the relocation contractor gave Milton his telephone number. The DADS case manager also gave Milton her telephone number and the number of the home health agency in case Milton had any problems or questions that needed attention before her next contact; he was also told who to call in case of an emergency.

As indicated in his service plan, the direct services staff attends to Milton a few times a week as required, and the case manager periodically checks on Milton to ensure that he is adjusting to his new living arrangement and that the services authorized in his plan of care are being delivered.

However, one day, his direct service worker failed to show up as scheduled. When Milton tried to get himself in his wheelchair to go to the phone, he began to feel very dizzy and had to lie back down.§ For a few minutes he panicked and then remembered his Emergency Response System (ERS) device he received through the CBA program as part of his back up system. Milton followed the directions given to him by his service provider, and punched the button on the ERS device which was programmed to go to: (1) the home health agency emergency number and to (2) a neighbor downstairs who had volunteered to be unpaid support for Milton in an emergency. As part of the emergency backup plan, the neighbor had a key to his apartment. Within the next five minutes, he heard the neighbor unlock his apartment door and announce herself. Then the phone rang and the neighbor handed it over to Milton. It was the home health agency. Milton said that his worker had not shown up and that he needed the agency to send a back-up immediately. Within the next hour another attendant from the agency arrived.

The home health agency filed the incident on their complaint log and indicated the actions taken to remedy the situation and steps taken to prevent a reoccurrence. The complaint log was reviewed by DADS in their next on-site inspection.

Over the next three month period, the relocation specialist will visit Milton four times in the first month, two times during the second month and once during the third month. In between these visits, the relocation specialist will talk to Milton over the telephone on an as needed basis. Finally, the DADS case manager will visit Milton at least every six months unless circumstances warrant more frequent contacts.


Updated: May 1, 2015