New Jersey's Community Choice Program

Too many older people and their families assume a nursing home is the only option when they can no longer live independently at home.

In 1998 the New Jersey Department of Health and Senior Services (NJ DHSS) began the Community Choice Program. The purpose of Community Choice is to offer counseling and educate seniors, people with disabilities and their families about long term care options for housing and services; assist individuals with transitioning to community-based settings by working in partnership with consumers, families and the provider network; and act as a resource for consumers and health care providers to learn about available long term care options in their communities and how to access them. By providing these services the Community Choice Program supports individuals' rights to choose the setting in which they want to live.

Community Choice hired Registered Nurses and Social Workers as counselors to seek out nursing home residents that were capable of and desired to live in the community. Counselors are assigned to nursing facilities (NFs) across the state and work directly with individuals and their families to assess care needs and explore options, then assist to whatever extent needed with every aspect of the transition back to a community setting. They work in cooperation with NF discharge staff, local providers, county boards of social services, assistive technology providers, Area Agencies on Aging (AAA), physicians, and any other agent that participates in the process. Counselors establish a network in the communities in which they work so that they are able to connect people to the resources that are available. For example they visit all of the senior and subsidized housing sites to find out about availability and perhaps put peoples names on waiting lists. They also visit the local Assisted Living Residences to learn if they are Medicaid providers, determine if there are openings, and establish working realtionships . Counselors visit the AAA and work very closely with the staff and their contracted agents to remain up to date on services available. They work with the other departments in the state that provide services such as home and community based waivers and congregate housing programs.

When the program began we started by focusing on NF residents. In September of 1999 New Jersey was a recipient of a Centers for Medicare and Medicaid Services (then HCFA) Nursing Home Transition Grant. The grant has helped tremendously in expanding the program. We have been able to develop our educational and marketing materials, develop our quality assurance program, identify the barriers to implementation and develop remedies.

We recognized that we needed to begin the educational process about long term care options before a person is admitted to a NF and preferably before a crisis developed. As a result we began to expand our educational and counseling programs beyond the nursing facility. First with a Hospital Demonstration Project in nine hospitals across the state; then by reaching out to consumer groups such as AARP, senior citizen groups; and finally to providers, particularly physicians because patients and their families rely heavily upon them for recommendations.

In the hospitals we are working directly with the hospital discharge staff to counsel patients and families about long term care options. This is a crucial time for many people; they have had a crisis and are now faced with making a decision under duress. Patients and their families are not prepared with information about options and there is little time to do research. Often they believe they have no choice but to enter a nursing home and remain there; the patient or family then gives up the home and there is little likelihood that the person can return to the community. Affordable, accessible housing with or without services remains in short supply even in New Jersey where the Governor's Senior Initiatives have dedicated funds to expanding subsidized housing with services programs and more and more assisted living residences are becoming Medicaid providers. We encourage individuals and their families to maintain their homes. By counseling people in the hospital setting we can prepare individuals and their families for a short term NF stay and begin the process of education, counseling and assistance in making long term plans that meet the needs of the individual and help them to remain in their community.

We have begun an education and outreach effort to the physician community since these are the providers who can and often do have the most influence about long term care decisions. We have found that physicians need easily accessible and concise information about long term care options. The system of eligibility, different funding streams, and the variety of services has become more complex; it is no longer a simple matter of referring to the local nursing home.

We have had to develop materials to help consumers and providers learn about long term care options and the Community Choice Program. This led to the creation of brochures and booklets aimed at different audiences and a website about the Community Choice Program(www.state.nj.us/health) so that consumers and their families can easily get information about the program and options. Through the website they can contact us via email and ask specific questions and we respond directly with specific information and referrals. Most of our email comes from seniors themselves or adult children who want to know how to arrange in-home services. One of our most frequently visited features is our Housing Alternatives section which describes the three assisted living (AL) settings, alternate family care (AFC), residential health care facilities, and subsidized housing in New Jersey. Other website features include, frequently asked questions (FAQs), services and programs, publications, and useful links to other Internet sites.

Community Choice cannot work in a vacuum. It depends upon other systems throughout the state and those supported by the Federal Government to assist seniors in exercising their right to choose how and where they receive long term care services.

The primary obstacle to achieving this goal is lack of appropriate housing in the communities in which seniors live. This is being heard from every corner of the nation. Not only is the supply of affordable, accessible housing for seniors falling short of the demand, it is extremely difficult to locate and then access the housing that does exist.

In New Jersey alone there are 83 Public Housing Authorities. To locate available housing and apply for Section 8 vouchers is a complicated, time consuming process for young, able-bodied adults. Seniors often meet with a great deal of frustration and then give up. It requires understanding of complex regulations, traveling from place to place to complete applications and a lot of telephone calling to get the information to initiate the whole process. This was surely never the intention of Congress as it established these programs some 25 years ago. The many layers of regulation have created a system that is difficult to navigate and now, more than ever, needs to be accessible to the people it is intended to serve. In New Jersey we anticipate the population of people over aged 65 to grow from it's current 1 in 7 to 1 in 4 (25%) by 2030.

Once housing is located and made available there are the costs associated with moving from a NF or home in the community to another location. In New Jersey part of the budget for the Community Choice Program includes a Relocation Fund. This fund is used to pay for relocation expenses such as furnishings, rental deposits, household items, initiating utilities, and any other identified needs that would preclude the person from moving to appropriate housing. While not every person assisted by Community Choice needed financial assistance, those who did would have not been able to make the transition without it. Traditionally these funds are not available through Medicaid since these services are not health related. Without these funds many people would have remained in nursing facilities. This fund has been an essential component in making the program a success.

The lack of services and service providers presents another obstacle for seniors wanting to remain in the community. Again, this is a national issue. Even where services exist, the decreasing supply of providers has put programs in jeopardy. New Jersey has embarked on several new programs to offer consumer directed care as one way of coping with this problem. Consumers have proved to be savvy purchasers of services, but not every program fits every person and New Jersey has taken great strides in developing community-based alternatives for seniors.

Some examples include our use of Home and Community-Based Medicaid Waivers. These have been vital in making transitions a reality in New Jersey. The DHSS administers two: the Community Care Program for the Elderly and Disabled which allows individuals to receive services in their home and the Enhanced Community Options (ECO) Waiver which provides services in any of the three AL settings, as well as services provided in AFC. Last year the Office of Waiver and Program Administration amended the ECO waiver to include an in-home services component called the Caregivers Assistance Program (CAP). We have also created a state-funded program called Jersey Assistance for Community Caregivers (JACC) for individuals age 60 or older who do not financially qualify for Medicaid. CAP and JACC both offer consumer directed care options and use caregivers as the foundation of support.

All of these programs were designed to offer alternatives to nursing facility placement. Their success, however, does not lessen the importance that more supportive housing alternatives are necessary to effectively meets the needs of the growing senior population.

For seniors, a viable alternative that marries housing and services is New Jersey's Congregate Housing Services Program (CHSP). This housing program provides affordable, accessible housing with personal care services, homemaker services, nutrition programs and supervision that provides coordination of services. It also provides a community for people who often find themselves isolated at this stage of life.

Options such as these have made it possible for the Community Choice Program to transition seniors from nursing facilities to community-based settings. We hope that this hearing will help to promote further growth of these kinds of alternatives to nursing facility care.

To conclude, in order for seniors to exercise their choice there needs to be a wide array of housing and services available not only to keep pace with the growing senior population, but also to meet the changing needs of seniors to allow aging in place. We must continue to educate consumers, their families and health care providers about the options that exist and offer transition assistance. Programs like New Jersey's Community Choice help seniors in making their long term care decisions by promoting dignity, independence, and informed choice