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 42 states plus the District of Columbia 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 (DA) 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 (A&D) Waiver, Traumatic Brain Injury (TBI) Waiver, or the Developmentally Disabled (DD) Waiver. Individuals must also be Medicaid eligible one (1) day prior to transition.

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 Transition Care Team, consisting of a Transition Specialist, Transition Nurse and Outreach Coordinator during the transition process. The Transition Specialist will remain in contact with participants for 365 days. On day 366, the MFP participant, upon continuing to meet nursing facility long-term level of care, will transition to one (1) of the following waivers:

1. Aged and Disabled (A&D) Waiver
2. Traumatic Brain Injury (TBI) Waiver
3. Developmentally Disabled (DD) Waiver

• Meet nursing facility long term care level of care
• Have lived in a nursing facility and approved for long term care placement for at least 90 days
• Be Medicaid eligible one (1) day prior to transition from nursing facility
• Have health needs that can be met through services available in the community
• Voluntarily consent to participation by signing a consent form
• Move into a qualified residential setting, including:
  • Home owned or leased by the individual or the individual’s family
  • An apartment with a personal lease with lockable access and egress which includes living, sleeping, bathing, and cooking areas
  • A residence in which no more than four unrelated individuals reside over which the indivdual or in indivdual's family has domain and control.
  • Assisted Living
  • 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 Transition Care Team, consisting of a Transition Specialist, Transition 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 Transition 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 budget 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, home-delivered meals, transportation, and housing
• Ensuring that community-based needs are met after discharge from the nursing facility and continuing to meet appropriate level of care.
• Educating family or support persons on their role during the transition 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