IL-NET T&TA Center
CIL PANDEMIC RESPONSE
Thursday, March 11, 2020 
Presented by Jodie Baney, Misty Dixon, Anaya Robinson, Tim Fuchs
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>> TIM FUCHS:  All right.  Welcome folks.  I am going to give 20 seconds to make sure everyone is connected before we start.
>> TIM FUCHS:  I will give about five more seconds to make sure everybody is connected before we start any content today.
All right.  Thanks for waiting.  Thanks for being here.  I'm Tim Fuchs with the National Council on Independent Living and I want to welcome you to today's webinar, CIL Pandemic Response: How CILs Can Initiate Emergency Relocations and Transitions During the COVID‑19 Pandemic.
Today's presentation, of course, is brought to you by the IL‑NET for CILs.  The IL‑NET is a project of ILRU in collaboration with NCIL, April, and ‑‑ excuse me.  University of Montana.  With support for the project provided by the administration for community living at the U.S. Department of Health and Human Services.
I want to run through housekeeping.  We are recording today's webinar so we can archive it on the website.  We are currently in presentation mode, so you all are muted.  You don't have to worry about your cameras.  But we are gonna leave ample time for Q & A today and I'll talk about the Q & A process in a moment.
Before you I do that, I want to make sure that everyone knows that we do have captioning available today.  Along with ASL interpreters.
So in order to keep our active speaker and ASL interpreters front and center, our other speakers have turned their cameras off and will turn them on as they present.  I think you all are pretty accustomed to that by now. 
I am screen sharing so you should be seeing slide 2 which is our title slide.  If you'd like to adjust the camera size, especially to enlarge the camera of our interpreters, you'll want to make sure you're in side‑by‑side mode in order to enable that mode, you should have a message at the top of your screen from Zoom that says tic is sharing his ‑‑ Tim Fuchs is sharing his screen.  There's an option and you want to select side by side.  If you're using dual screens, select the dual screen optimization box under those options.
If you have any trouble finding that, any trouble changing the size of the cameras or slides, let us know in the chat and we'll give you a hand there.
For questions today.  This is a panel style presentation so we're gonna have some discussion questions of our own to get this started, but when we end today we will have plenty of time for audience questions.  I want to point everyone to the Q & A feature in Zoom.  That's a handy way to submit your question.  You can enter it in it during today's presentation and we'll address it during the Q & A break.  If that feature is not accessible or convenient for you, there are a couple of other ways you can submit questions today.  So first you're welcome to e‑mail me.  My e‑mail is Tim@NCIL.org.
You can also if you're only on the phone today, you can press star 9 on your telephone keypad and that will indicate to us you have a question and we can unmute your line.  If you're also connected to Zoom and these other options are accessible to you, I would like to ask that you, please, reserve that option for people who are only on the phone or need it as an accommodation.  We won't have time with an audience this size ‑‑ we've got several hundred people registered.  We won't have time to go to everybody's lines and unmute them for audio questions.
Also there is an evaluation form today.  So I want to ask that you, please, take a moment or two after today's webinar.  We actually have it preloaded in Zoom so when I clothes the webinar today at 430 eastern the evaluation will pop up on your screen and if you take a minute to fill it out, we would really appreciate it.  All right.
I'm going on to slide 3 here where I should have gone a moment ago PPP next on slide 4.  Meet the presenters.  There's my name.  Tim Fuchs and my e‑mail.  Oh, I neglected ‑‑ we're gonna be visually descriptive as possible today including all the content of our slides, but I'm Tim Fuchs.  I'm a white man in my 30s.  I have dirty blond hair sitting in my home office still remote working during COVID wearing a gray button‑up shirt.  With us also today ‑‑ I want to thank our panelists for taking time out of their schedules to share what they have built and what they know with you all.  We have Jodie Baney from Roads to Freedom and she is director of programs and service.  Misty Dion, and Anaya Robinson who is Associate Director at Atlantis community in Denver.  Thank you so much.  I know your schedules are packed and I can't tell you how much I appreciate you being willing to take some time this afternoon to share your expertise with us.
Here on slide five I want to quickly walk through the objectives.  So this is what we're promising that you will learn today.  We are gonna talk about how emergency relocation or emergency transition programs during the pandemic differ from the core service of transitioning consumers out of institutions and congregate settings.
We'll talk about the staffing, funding and community partnerships utilized by presenters to build emergency relocation and transition programs that offer safe alternative to say nursing homes and other congregate settings.  And we'll give examples of major challenges encountered during pilot programs at two centers for dependent living.
So before I ask the first discussion question here, I want to encourage you all to please feel free to use the chat, especially if you have any technical issues today.  We'll be happy to give you a hand there.
And we want to ‑‑ I want to encourage you to use the chat for technical support and the Q & A and the other options I offered for content questions.  It will help us divide that.  Obviously, if you need technical support for the chat ‑‑ but the chat is not accessible, you're welcome to use those other options, e‑mail me.  We'll give you a hand if you have technical problems today.
So I want to start here with this first question.  We're just gonna give an overview of these programs.  Anaya Robinson, can you just give us a quick overview of Atlantis' emergency transition program.
>> ANAYA ROBINSON:  Yeah.  Hi.  I'm Anaya Robinson.  I am for visual descriptor 35 years old Latinx trans man with black rimmed glasses, black crew neck sweater sitting in my office with a very bare wall behind me.
So our emergency transition program that we have implemented we started planning and creating the program back in April of last year and began implementing a couple of months later once we secured enough funding.
The program that we have, we created a partnership with a couple of hotels in downtown Denver and we are moving folks who are in congregate settings of all types into those hotel rooms.  So we're working with people transitioning out of the nursing facilities, acute care hospitals, congregate shelter settings, any type of space essentially where socially distancing is not possible for the folks living in those spaces and where we know significant outbreaks of COVID had occurred.
So we're helping to move these folks into hotel rooms for period of time to get the services they might need set up.  We have partnered with our state division of housing to get access to some state housing vouchers that we connect folks to while they are in the hotel and then we provide support to help identify housing that they can use those state vouchers at.
We're also partnering with an organization in Denver called reciprocity collective that is supporting the employment side of the pilot and they are helping us identify individuals who are currently experiencing homelessness who are looking for employment options and might be a good fit to provide attendant services to the individuals we are transitioning.  Once those folks are identified, we are getting them hired by one of the in home support services agencies in our area to provide attendant services through a consumer directed service delivery model in Colorado.  So these individuals can provide services and can be trained by both the agency and the individual in how those services need to be provided.
And then because it is a consumer‑directed model, they don't need to have the same licensure or certification as they would in a traditional home health model.
Those folks who are experiencing homelessness who are getting hired on to provide the care are also being moved into the hotel rooms with the hope that those individuals are able to build community and build relationships with the individuals they are both providing care for and receiving care from.
And help build that trust and relationship in that space and then the hope is that the ‑‑ the individuals providing care are able to spend that time in the hotel with paid employment without living expenses so that they're able to save money to get themselves housed as well once we're able to get the folks we're transitioning into permanent housing with their voucher.  That's kind of the quick and dirty run down of what we're doing.
>> TIM FUCHS:  I'm sure it feels like an over simplification after the last year.  But thanks, Anaya, that's great.  I will come to the folks at Roads to Freedom.  Misty or Jodie, do you want to give the overview of the program you built there.
>> MISTY DION:  Hi, PPP hi, everyone for visual description my name is Misty Dion and I go by she, her.  I am a fair skinned 37 years old white woman with glasses and long brown hair with a white shirt sitting in front of a green, leafy background with a waterfall into a mountain stone catchment.
And my name is Misty Dion.  I'm the CEO for the Roads to Freedom Center for Independent Living in Pennsylvania and have had the opportunity to work here for, I think, I'm on my 16th year, and work with transitioning for many of those years.  
So our relocation efforts really came as a result of our long history with transition program.  Early on in the pandemic, we noticed that some of the individuals on our transitioning list were passing away and this had not really been a situation that we experienced at the rate ever before.  So we really began reaching out to the residents that were in our transition program to offer them safety and the ability to cohort in a hotel setting and see if there was any way we could expedite our transition.  Our emergency relocation program really is just that.  It's our transition program sort of on steroids.  We work to continue the process while the individual is based in the hotel with more control over the individuals that are delivering services, who they come in contact with, and like Anaya mentioned earlier, many of the individuals that we're working with whether in a nursing facility or another congregate setting, they're sharing bathrooms and phones with many people and we see where that got us during this time.
So the stark difference I guess with Roads to Freedom's relocation program is we have also a PAS license so we can provide attendant care services.  So much like Anaya does, we reach out and recruit attendant care, direct care workers, train them, recruit individual supports that the individual already has or, you know, if there's a way we can help use live‑in caregivers during the time we're training other supports.  So we work that into the mix as well after planning the relocation for the individual.
So that's a little bit about the difference.  We've worked more advocacy related with the homeless population and shelters to ‑‑ the systems change and the availability of this emergency relocation response similar to how the homeless have received FEMA and other COVID relief, we're sort of trying to work together to see if we can make sure that the individuals in these congregate settings are given that same relief.  I'll turn it over to Jodie to give a little bit more if there's anything I missed.  Jodie is our nurse and director of relocation and transition services and was instrumental in helping to provide those transition care plans. 
>> JODIE BANEY:  Hi, everyone.  My name is Jodie Baney I'm a registered nurse also the director of programs at Roads to Freedom Center for Independent Living.  I am a white female, age 30s, I have long red hair, round glasses, identify as she.
As Misty and I have said, emergency relocation is nursing home transition so steroids.  It is the transition process that just happens quicker.  I always explain it as they get the same services in the hotel setting as they would in their own home.  It's just a different location.  During that process, we are looking to coordinate care afterwards so from day one we're coordinating what's next, what happens after the hotel, where will they live, what kind of services will they need to be successful and we're building upon that.
>> TIM FUCHS:  All right.  Thanks, you all.
So I wanted to get into more detail here.  I will go to the next slide so you can see the next discussion question with me.  I'm on slide 7.  Anaya, I will come back to you.  How did you all fund this work at Atlantis.  That's the burning question for everybody.  CARES Act has been a huge Boone this past year but are there funding opportunities beyond that that CILs can use.  And how did you do it.
>> ANAYA ROBINSON:  So we have been using a good portion of our CARES Act dollars to fund this pilot and I think we've found that there are still some gaps in what we're sometimes able to use CARES Act and Part C funding for and had to figure out other ways to meet the needs in those particular areas sometimes.  We've also ‑‑ we're partnering with some other local organizations in this pilot and collectively have received some foundation grants, some local government grants as well to help fund portions of the pilot and we've also received a decent amount of individual donations through partner organizations for some of the funding as well.
I think because of the current situation, we found a lot of funding opportunities, grants‑wise, that we could apply for.  Some we received and some we were denied.  But I think at this point during the pandemic because we see a lot of those opportunities decreasing, we're now trying to look at more stable funding streams to start applying for that might go into more two year, three year grants, rather than the COVID specific funding streams that we've been reaching for that are maybe six months at a time for funding.  So we've really had to piecemeal a lot of different streams together to make this work in the past year.  And we're really more intentionally looking at funding that will last us a little bit longer so that we can continue this pilot throughout the remainder of this year and hopefully well into next and utilize the opportunities and the flexibility that we have in this pilot that don't exist in our Medicaid state transition programs to help make sure we're moving folks as quickly as possible during this time and we know that there's a lot of focus on the vaccine right now and we're really grateful that people are getting it and more is coming but we know that as with most things our community is going to continue to experience the brunt of the negative impact of COVID and we want to make sure that just because a vaccine has been made available we're not forgetting there are people who still need to get out of those congregate spaces as quickly as possible so we're trying to find ways to continue to fund this work while the outbreaks might lessen a bit here, we know it's still really important to be able to move people as quickly as possible and in this pilot is the easiest way for us to do that right now.
>> TIM FUCHS:  All right.  Thanks, Anaya.
So Misty, how are you all paying for this work currently and what opportunities do you think other CILs might have that they should be aware of.
>> MISTY DION:  Much like Anaya, we are one of the federal CILs who received CARES Act funding, and like Anaya mentioned, vaccine reports some of the staff and the facilities, I think, the latest percentage that we saw was less than half of the long‑term care facility staff were getting vaccines ‑‑ vaccinated.  So it's really important to look at.  We're not out of the pandemic and it's gonna be around long after COVID and needing to be able to respond and provide emergency.  And so funding is an important concern of ours and how do we bring funding to continue.
We've used the CARES Act dollars and we've also applied and received ACL COVID relief fund that went through the aging and disability resource centers.
With the reauthorization that money follows the person, some of the states may be able to use some of the Medicare COVID relief dollars that were in the one of the recent care packages depending on whether your state is managed long‑term care.  We were able to contract and work collaboratively with our managed care organizations to create support and funding for some of the individuals who wanted to relocate and or are on the transition list.
So there are some of the ways that we've coordinated services and supports and funded some of the relocations.  Our agency also applied and received the PPP loan and forgiveness.  Some CILs might be able to take advantage of to provide relocation services.  I know in Pennsylvania, we have half of our CILs that are state funded and did not receive CARES Act funds.  So we've worked to sort of advocate for future funds and in a program ‑‑ I'm not sure if any of you have heard of the silver pilot program but it's a national effort that Anaya and I are working with many other advocates nationally and disability‑led organizations and disaster relief organizations to request for future grant funds to be allocated for relocation and to assure that option is available as we continue to fight the spread.
>> TIM FUCHS:  All right great.  Thanks, Misty.
All right.  I will go ahead to slide 8.  By the way I see some great questions coming into the Q & A.  Just a reminder keep them coming.  We will wait until the Q & A break at the end to address those.  I'm on slide 8 now and Anaya, speaking of funding and resources, how did you all staff this work?  What did that planning and rollout look like and what are the resources did you find you needed?
>> ANAYA ROBINSON:  Yeah.  So internally we have staffed this pilot with our community transition coordinator along with our mobile unit staff.  So at Atlantis we have a mobile unit side of our IL programming, and those staff predominantly work with people experiencing homelessness and folks in the more rural parts of our region.  But because of a decrease in ability to go do the same type of outreach activities we were prior to the pandemic, we were able to move them over into this pilot to help support that work on a consumer side.  We also are partnering and have been since the beginning of creating this pilot with several other community organizations to help support the areas that we don't necessarily have the same expertise in.  So making sure that we're pulling in the right partners to be able to provide the most experience and knowledge and support when it's something that we might not be the experts in.
So we have ‑‑ one organization we're working with to help us identify caregivers and do some screening on that end and get them set up with the IHSS agency we're working with to get them hired on.  We're working with another local partner for our coalition as a whole to do some of the grant management for the project.  Also helping support some data collection and analysis so that we can utilize some of the data that we pull out of this pilot to hopefully provide to our state Medicaid office so they can use some of our data to help inform potential changes they could make in rule and in their program processes to hopefully reimagine their transition benefit to be able to be a little more supportive of individuals with better timelines, better outcomes, and more flexibility is, I think, as we all know a lot of times in bureaucratic systems those programs aren't able to be as flexible as they need to be to meet the needs of individuals in the ways that are more supportive.
So we know having not hired or created any new position to say roll this program out, we really needed to bring in some of our local partners to help support on those ends so that we can make sure we're running this program in a way that is fully staffed when we're not necessarily the only entity and not able to fully staff all aspect that we know are important.
>> TIM FUCHS:  Great.  Thanks.
I think this pandemic is obviously highlighted things that were ‑‑ had always been set in stone that suddenly we found, oh, these systems can change [chuckles].  When they're disrupted and suddenly options and accommodations that had been impossible months before were optional and that doesn't mean it's been easy to change that.
Anaya, I wanted to sneak a question in because we've got a popular question.  Everybody is dying to know and I will pose this to Misty and Jodie.  Everybody is dying to know the timing here.  How long have people been staying in hotels or temporary environments before they're able to move into permanent housing?  What does that look like for you all in the Denver area.
>> ANAYA ROBINSON:  It depends on the person.  We had one individual who we were able to secure housing for so quickly that he didn't even end up needing to go into the hotel.  And we've had other individuals who spent eight weeks in the hotel.  I think on the grand scheme, it's an average of probably about 30 to 45 days that they're spending in the hotel while we make sure we get everything set up and work with them to figure out where they want to live and what they want their life to look like and what they need to make that happen.  But it's an average of right about a month, maybe five weeks.  But we really are trying to do our best to remain flexible because we know as with most of the country, housing is a really critical need right now and there's never enough of it.  So we want to be able to be flexible in knowing that if we've exceeded the time that we thought it might take to find somebody housing, we feel really, really solid in making sure that we're keeping them in a stable space for as long as they want to be there and as long as it takes us to make sure that they have what they need to get into permanent situation in the community.
But it's definitely been a challenge and depending on the individual and their needs and their background, it can take longer or shorter and some of it is the inventory that pops up when somebody gets their voucher and sometimes the timing works out perfectly and sometimes it unfortunately doesn't.  But we're really committed to making sure regardless of the time frame, we are there to support our consumers through this process for as long as they need to be in whichever situation they're in.
>> TIM FUCHS:  Thanks for adding that.
For all the COVID fixes and advocacy we're able to do, the housing ‑‑ this housing behemoth has not been fixed.  I always love to think about people hearing about the mobile unit at Atlantis the first time and going, you have what?  It's such a cool program and solution.  Just wanted to point that out. 
Jodie I will come to you next for this same question.  So how did you all staff this work and what other resources did you need?  I can prompt you later, but after you answer that, if you could talk a little bit about the average time that folks have spent in hotels before they moved to temporary ‑‑ excuse me ‑‑ to permanent housing.
>> JODIE BANEY:  So, yes.  We also used staffing within.  We didn't create any new positions so myself as a registered nurse, I did some of the assessments.  We used our nursing home transition coordinators to kind of be the care coordinators.  We also partnered with a lot of outside providers.  So we worked with the facilities social workers, working with service coordinators for the managed care organizations.  We also partnered with other agencies to provide live‑ins.
And then really just worked on hiring for PAS and staffing.  The other resources is just that we really had to tap into those community partners really focusing on ‑‑ we were fortunate here, Misty knows a lot of people and some of the business owners, they owned multiple different types of businesses so hotel owner, he actually owned multiple hotels as well as restaurants.  So it was helpful we kind of had a one stop shop for that type of stuff.
But again we didn't create any new positions.  We just worked off of what we have here at the CIL.  And then speaking to the last question, I would say about a month's time as well.  We were ‑‑ we had a situation like Anaya where someone didn't need to go to the hospital and ended up going to a home setting.  We had another individual who was about two weeks.  So I would say if we had to put a number on it, a four to six week average.  And some of the positives of this process has been building new partnerships for people within the community which has opened doors.  I see a lot of comments about the housing barriers which I think every state in the United States is going through that to some degree as far as housing waiting lists but having gone through this, we've made new partnerships, met new landlords and it's really open the door for not only our relocation program but our nursing home transition program.  Thank you. 
>> TIM FUCHS:  Thanks, Jodie.
All right.  Just want a quick note to folks, I know we've got some really active conversation in the chat.  I just want to remind you all, if you have content questions put them in the Q & A.  I'll do my best to address questions from the chat if I can find them but the way it rolls and we've got a very big audience today, it can be tough to follow those.  So I will prioritize questions from the Q & A and then again if that Q & A is not accessible to you, you're welcome to submit questions to me at Tim@NCIL.org.
So I will go to slide 9 and we'll go back to Anaya.
You all have alluded to this and I know this is a big part of this to make this work.  So what community relationships did you leverage or build to pull this off over the last year?
>> ANAYA ROBINSON:  Yeah.  We have been working really closely throughout the entirety of the pilot with the Colorado cross disability coalition and our local adapt chapter in the creation and rollout phase.  We've also been leveraging our relationships with our region's Medicaid case management agency and our state Medicaid office to help expedite eligibility and service provision for the folks that we are transitioning.  We have leveraged our relationship with our state housing division as well to utilize some state housing vouchers that we have available in Colorado that were created to both transition people out of institutions and also to support diversion from entering institutions, which I think is a side of the diverse portion of that is a side of that appropriation for those vouchers that has been significantly underutilized in the state until the creation of this pilot.  
So the state was really excited to work with us on that side to be able to utilize that aspect of the authority for the funding of those vouchers and those vouchers were something that Atlantis also had a lot of part in the creation of the funding source for those vouchers through our State Legislature during Colorado as MFP program recognizing a significant gap in housing access for the folks we were transitioning in our state and understanding that access to housing vouchers would help alleviate some of that gap.  So Atlantis did a lot of advocacy work and support for the state when this option came to the table and worked really hard to make sure that the funding for that got allocated by our Legislature and also got included in the legislation that sustained dolls as MFP program into our Medicaid state plan services.  So we were able to get continuing funding for those state housing vouchers as well and that continuance is really a big part of what has made this pilot a success is still having access to those housing vouchers.
>> TIM FUCHS:  All right.  So I believe I'm coming to Misty for this on slide 9.  The question about what community relationships did you all leverage or building to pull this off in Pennsylvania?
>> MISTY DION:  Roads to Freedom in Pennsylvania did a lot ‑‑ made a lot of similar connections in terms of working with our state to expedite eligibility determinations.  Like Anaya, partnered with homeless shelters and disability‑led organizations.  I'm sure many of you are familiar with the partnership, but they have a weekly call and we worked with them and the world institute on disabilities and Marcie Roth to understand more about FEMA.  And then worked with our local and county officials to, you know, build a memorandum of understanding with the local emergency Management Agency to apply for FEMA reimbursement category B funds to cover some of the eligible costs for individuals who may not have COVID relief funds.  We've been working on an initiative with that locally and in our state so that some of the CILs without the CARES Act fund can build that.  And likewise if we were to be offering relocation services, I think I saw a question in the chat about what happens if somebody is in a hotel and funding runs out.  Category B funds would then be applied for and we would seek reimbursement for those funds. 
I will turn it over to Jodie but I wanted to make sure I answered some of those questions in terms of FEMA and how that's helping drive and support the emergency relocation funding that might be available for some CILs. 
>> JODIE BANEY:  This is Jodie.  I don't have a whole lot to add.  Misty did a great job of answering that question.  But for us it was really leveraging the community relationships that we had with the business owners.  For us ‑‑ and for them it was kind of a win‑win during COVID.  A lot of people weren't staying in hotels.  Restaurants were closed down or own for takeout.  So we had that leverage that benefited them and us and in the end our consumers win.  So we continued to collaborate with all members in the community to ensure that we have the right supports and services set up for our consumers.  Thank you.
>> TIM FUCHS:  All right, great.  Thanks you all.
Okay.  I will go to slide 10.  This is a big one, of course.  So this is not easy work.  Transitions aren't easy work outside of a global pandemic.  So Anaya, coming back to you here on slide 10, what major challenges did you all encounter and were you able to find solutions or are some of those ongoing?
>> ANAYA ROBINSON:  Yeah.  I think one of the biggest challenges we encountered was being able to get in touch with folks who are in congregate settings to make sure that they knew what their options were to leave those spaces during the pandemic.
All of the nursing homes in our region were locked down to visitors.  Most of the assisted living and hospitals and shelters also were locked down to visitors so we had to work intentionally with a lot of our partners across the community to get the information out to people who needed to be relocated when we couldn't necessarily get to them.
We were able to utilize some relationships and build some new relationships to get that information out to folks.  I think getting the information out to all of the nursing facilities in our region is still something that we're working on.  But we have been able to get to a lot more folks recently than we were able to in the beginning of the pilot.  So I would say that barrier has been half solved.
Again another major barrier was figuring out funding for the hotel rooms themselves.  We spent a decent amount of time in the beginning of our planning stages, and the beginning of implementing the pilot getting an affirmative from ACL that we could, in fact, use CARES Act funds to pay for those rooms.  And then with that information, we still had to work on securing fund for the caregivers to pay for the hotel rooms for them as well and help support our partner organization in figuring out how to ensure that.
And then because we're emphasizing noncongregate settings for this pilot, the numbers that we were putting into grant applications for the number of individuals we were trying to serve were significantly lower than the grant applications that funders were receiving for people who weren't utilizing noncongregate housing as a solution to COVID impact.  A lot of places were doing more congregate sheltering options or providing services that had nothing to do with shelter or housing and were able to really increase their numbers of people being able to be served because of that.
We also in that time of trying to secure funding had our local government really shut the door on us being able to access FEMA funds for the project pretty early on in the process.  They had already allocated all of the funds that they were willing to funnel from FEMA with a lot of the homeless services providers in our area and were working specifically with them to address congregate shelter issues and outbreaks for the population of folks experiencing homelessness, and because we got in probably a week too late with our pilot pitch, the city had already worked on executing contracts with those organizations and weren't really willing to reopen that conversation moving forward.
But we've also luckily been able to work really closely with Misty and a lot of other partners nationally to try to get FEMA to work ‑‑ to direct states to be able to contract directly with CILs rather than CILs having to go through their local offices so that with a lot of CILs in the areas that we cover, that means sometimes we might have to be contracting with ten or more local agencies to access FEMA funds and really trying to have a solution where because of that and because of the impact on our community, CILs would have an opportunity to just work directly with the states in offices rather than having to go through several local agencies to get access to the same thing. 
>> TIM FUCHS:  Great.  Thanks, Anaya.
I want to highlight Misty just put the category B funds from FEMA into the chat.  I know that access to the chat especially during a live webinar can be missed for folks.  One thing we'll do is when we upload the recording of today's website to the on demand page, will include the chat history so that way if you want to look through comments on resources, links, they will be there.  Okay.
All right.  So Misty I will come back to you for the same question on major challenges that you all encountered and how you were able to find solutions or whether some of them are still ongoing.
>> MISTY DION:  Thanks, Tim.  Certainly we echo Anaya's ‑‑ our biggest barrier has been being able to communicate directly with our participants, with our consumers and to get response and timely response from nursing facility staff whether it was because they were short staffed or what have you.  The conversations just, you know, there was a lack of responsiveness that made us have to be more strategic and intention am in reaching out to some of the highest affected facilities and referrals and just educating the local emergency management, the Department of Health, in our state there were these rapid response or ad hoc evacuation committees that were sent to these facilities, and there was testimony and cases where they really put the residents and workers into unnecessary risks because they didn't plan a relocation with our assistance or more importantly the individual's choice and involvement.  In many cases, it was just a matter of the residents would be shipped to other facilities and have no choice or get little choice to pick one of three facilities and maybe all three were in different counties.  Thereby removing the individual from the supports and services that they already had.  So the difficulty of being able to communicate directly with our residents, even if, you know, we were trying to get them technology in the facility, it didn't always have a lot of cooperation from the facility staff.
So we know the shelter‑in‑place strategy failed to save over hundreds of thousands of lives, so it's just ‑‑ it made it difficult to ‑‑ and it still is difficult to get the information to the individuals who most need it.  I think if there's anything that we've done and have been working on was creating more PSAs and more marketing and spending time educating the community and making sure people know that this is a response to an emergency.  Likewise, working with FEMA and other partners such as the partnership for inclusive disaster which they have a COVID hotline but to encourage people ‑‑ sorry not a COVID but a disaster hotline.  Encourage people to reach out, learn more about this and to spread the word.  I'm glad we're having this conversation because the more this conversation is had and people know they have the ability to relocate, if there is upfront costs associated with relocating somebody, FEMA category B funds could be something that they apply.  Like Anaya said there's still more work to be done to stream that process so that one CIL or one relocation provider isn't having to coordinate and apply with 15 different counties, but hopefully that answers the question.
>> TIM FUCHS:  I think it does.  Thank you, Misty.  Good examples.
All right.  So I want to go ahead to the next ‑‑ I want to go to slide 11.  Anaya, I'm wondering in your opinion, what needs to happen to advance this work.  This is kind of emergency, fast paced, triage work, and you all did this out of necessity because this was life or death stuff and you recognized that.  But I'm sure in hindsight you probably have thoughts about what this might look or how it can be improved going forward and how equity folds into this work.  Who might we be missing and how can we expand this work to be more effective, in your opinion?  Either you going forward but also guidance you have for other CILs who are picking up this work now. 
>> ANAYA ROBINSON:  I think moving forward we're really hoping to utilize what we have learned from this pilot and bring pieces of it at least into our future transition and diversion work.  I think getting more CILs to join us send Roads to Freedom in doing this work too, I think Misty and I would love to spend time talking with you all about the barriers you're seeing and what solutions might exist to get past those barriers to be able to do this as well.  And we would love to hear if there are CILs who've already implemented programs like this during the pandemic.  We would love to hear about them and maybe troubleshoot all of the issues that we've come across and the barriers that we have hit and see if we can help each other in moving forward.
I think one of the things that I would love to see too is some better direction and more enforcement and accountability from ACL around the core service of transition and specifically the diversion piece of that core service.  I think we miss a lot of opportunities as a community to provide support to individuals from entering institutions in the first place, and I know that funding and programming doesn't necessarily exist as readily available a way on the diversion side as it often does on the transition side and transition is hard enough even with those programs and with the support and funding.  But I think if we can collectively as a CIL network figure out how to drive that diversion side, we have the opportunity to really not see our community in the same situation and we were in at the beginning of the pandemic and throughout the entirety of it in watching as Misty said hundreds of thousands of families in this community die in a way that should have been able to be prevented by decreasing the numbers of people in institutions on the front end so that we don't see as many people who are really corralled in these congregate settings and don't have the opportunity to survive when we have a virus that is so closely related and impacted by proximity. 
So I would really love to see all of us as a community really putting our brains together and collectively identifying resources to figure out how to fully support diversion programs and also continue to do the intentional work of transitioning as well.
>> TIM FUCHS:  Great, thank you, Anaya.  
Misty, I will come to you with the same question.  In your opinion going forward what needs to happen to advance this work and who has this work been missing and how can Roads to Freedom and other CILs starting this work be more effective and equitable in running these kinds of emergency relocations?
 
>> MISTY DION:  I think ‑‑ we know that transition is a recent core service added and emergency relocations as Anaya said now more than ever many of us knew how risky congregate settings like this were and the high rate of infection but we need to see and make sure ‑‑ I'm sure we've all heard it, person‑centered planning and we know involving the consumer is essential.  Now, more than ever as we've seen and heard and know of stories of individuals who while in the shelter‑in‑place didn't have the ability to community for themselves and be actively involved in their transition plan or emergency response plan or quite frankly many choices we know that living in an institution does.  We need choice back.  We need each resident to have the ability to choose emergency relocation so that they can be in a cohort, a safe setting.  And involving the individuals, involving the Center for Independent Living, FEMA working directly with CILs and providers to provide emergency ‑‑ reimburse emergency relocation.  I think all those things are needed to see relocation, emergency relocation expand and be more effective. 
>> TIM FUCHS:  All right.  Well, we are right at 4:00 o'clock.  We've plenty of time for Q & A as promised.  I will mention a couple of things first as we transition to our Q & A.
First of all, I want to give a response and kind of a plug.  We got a great question in the Q & A from angel about if any of these folks come out of the criminal justice system.  That's very much on our mind.  Our panelists can correct me.  I think most of these folks that have been in these pilot programs have transitioned out of nursing homes and traditional institutional settings.  It's very much on our mind.  All congregate settings have been dangerous during COVID and we're planning a whole 'nother web in addition in, I think, mid‑may so be on the lookout for a date there, all about jails, prisons, other congregate settings.  Homelessness and shelters.  So ‑‑ and that may not be specific to COVID emergency relocations but what resources exist for those folks.  How are CILs working with them?  How should CILs be working with them?
And I've got some folks in mind for that.  I try to keep up on what's going on around the country.  But it's impossible to know everything.  So if you all have effective programs there, please do let us know.  We've talked a lot in the last couple of years about hospital transition, and transitioning from hospitals to the community.  Rehab interventions.  So we really do want to get to again criminal justice system, homelessness, shelters, reach out and let me know if you have resources or if you'd like to be a part of that and just know that that presentation is coming because it's a really important question.  I just wanted to address that.  Okay.
All right.  One last reminder for the Q & A, so we've got a lot of questions already in and I'm excited to get to these.  Again you can type your question in the Q & A tab.  Remember for those who have been leaning on the chat, if you have a content question, please do post it in the Q & A.  The chat rolls quickly.  It's hard to keep up with.  I will try to catch some of those if we have time.  If the Q & A is not accessible to you or not convenient, you can always submit your question to me at Tim@NCIL.org.
So let's start rolling through these.
I will start at the top with some of the once that came in early in the presentation.
Let's see ...  So Kelsey asked, we have a lot of individuals that we work with that don't have documents like a social security card or an ID or driver's license or birth certificate.  How do you get those in a timely expedited manner and I'll aid especially during COVID when offices like that are restricted or shut down?  Do you take people to social security office.  Do you agree with them to the appointments?  What's your approach there.  I imagine you both have things to share here.  I saw Misty typing.  
>> MISTY DION:  Primarily these individuals are in the nursing facility and rarely able to leave.  So we've not been able to take them like we once had.  In other cases we would.  We've done work and coordinated with the different offices to try to get ‑‑ to be honest it was a slow process.  It is a show process.  But relocating and moving them into the cohort setting allowed us to be able to take our time, but make sure that we stayed on top of these different facilities to get the documentation.  It was still sort of a push and a lot of following up. 
In Pennsylvania, Medicaid eligibility determinations were sort of the ‑‑ the lack of working with the state to expedite that process so we had to stay on top of those individuals and sharing that information with the state as soon as possible.  And then that's really ‑‑ that would only be needed for the Medicaid funding.  The rest of the documentation we had time to get it and they could be in a hotel setting and not have to wait for that.  So it sort of helped us with a staff gap.
>> TIM FUCHS:  Great.  Anaya, you want to add.
>> ANAYA ROBINSON:  We've noticed a lot of same things that Misty talked about.  Sometimes a lot of those pieces of identification take time to get. 
Having folks in the hotels allowed a lot more flexibility on the ways in which we were able to support folks in getting identification documents if they didn't have them.
Another thing that we've been able to kind of leverage is if they are already in a system with a state department, we've sometimes been able to get that state department to give us a letter basically verifying their identity because they already had as that department and utilize that with our other State departments to verify identity until we can get those documents into their files for whatever benefit type they might need to apply for.  So that helped us buy sometime of using existing state department systems who have already verified that identity to kind of help us push that with the other departments that we need to push it within ‑‑ to give us a little bit more time to get things lined up for folks without them having to wait longer for the services they need while waiting for those documents to come through.
>> TIM FUCHS:  Great, thanks.
So popular question from a number of people, folks are wondering about how many people have come through the program.  So Misty, I'll come back to you.  How many people have gone through the program for Roads to Freedom.
>> MISTY DION:  We've relocated only four individuals through our relocation program.  We transitioned 50 last year and like I said it was sort of a mix and just the added support that we put on to our transition program.  So although it was small it was mighty and we've had the opportunity of seeing those individuals live and hopefully continue to expand that number. 
>> TIM FUCHS:  All right.  Anaya, how about at Atlantis.
>> ANAYA ROBINSON:  So we have ‑‑ through our pilot we've had four folks who have now moved into permanent housing.  We have five consumers in hotel rooms right now and then about seven referrals that we're working on getting them moved into hotel rooms as well.
And our partner side, with the caregiver employment portion of the pilot, they have had three of their folks be able to obtain permanent housing through having paid employment while they're in the hotel rooms as well.  The three folks who were previously experiencing homelessness outside of our consumers were also able to obtain permanent housing.
>> TIM FUCHS:  Great.  Thanks.
So Maria is wondering if you all have run into any problems with your Medicaid guidelines and she shares, clarify even under the best circumstances in Ohio, transition [audio distortion], have you had any problems or got any flak about those program guidelines and bureaucratic issues during your transitions?  Jodie, I'll come to you if you want to respond.
>> JODIE BANEY:  Hi, everyone. 
I wouldn't say necessary flak from the state level.  People saying you can't take people out of nursing homes and put them into hotels.  That's unsafe.  We had a lot of push back more so than positive support in the beginning.  But as we were able to do it and successfully do it, and share those stories, that opened people's eyes that this can be done and should be done.  But we did everything in accordance with Department of Health as far as the PAS side, it's regulated through the state.  We made sure to follow all that.  We worked in conjunction with the managed care organizations so they were a part of it from the beginning.  But we didn't have much resistance. 
We just continued to push through it.  Thank you.
>> TIM FUCHS:  Thanks.
>> MISTY DION:  Tim, I'll just add in some cases ‑‑ I think the question was how can this be done in a hotel and quite frankly what we've found that in the hotel setting, we even had some additional supports that were not an opportunity in the community.  So some apartments, people may not have neighbors close by and in the hotel setting not only did you have the direct care worker, we certainly like Jodie said coordinated all the efforts.  A lot of was just educating individuals.  Sometimes this is the first time people are even hearing about transitioning and people from nursing facilities or people are living in nursing facilities or long‑term care facilities that really just didn't have the option or know about community living and needed access to it.
So as we educated on the supports and systems that are already available in the community, like Jodie said, we get more buy‑in and cooperation from some of the facility staff and just the public.  So, the hotels ended up providing more supports.  We had restaurants within the hotels that sometimes offered food, would provide meals.  The direct care workers could provide food to them and they could make the phone.  If they had a kitchenette or anything they needed so accessibility was a plus in hotels so those were some of the added benefits we found from using the hotel setup.
>> JODIE BANEY:  We actually had one of our individuals who wanted to remain in the hotel because it was accessible and everything was readily available.  They were close to stores and those things. 
>> ANAYA ROBINSON:  We saw a lot of same kind of push back in the beginning too of folks not quite understanding how we would be able to provide adequate support to folks in a hotel setting and the more folks who went through it and the outcomes that we saw, I think, a lot of that concern was alleviated for a lot of folks.  We also had a lot of nursing homes that we historically work with for transitions.  You don't necessarily like the long timelines that state transition programs can take and they have been really excited to work with us in this pilot because we are able to move people out of the institution and into a community setting through the hotel so much more quickly that a lot of the nursing homes in our area have started requesting to transition only through the pilot and not through the Medicaid program.  I think one of the other things that we were able to kind of avoid any of those programmatic restrictions through this pilot is we're not billing Medicaid for these transitions.  So we don't have to necessarily align the pilot program with the bureaucratic requirements of transitions that were normally restricted within.  So that's really allowed us to be a lot more flexible and figure out what the individual needs of our consumers are and how to best meet them in the most effective and efficient and supportive ways rather than the ways that our Medicaid programs allow.  So we've been able to be a lot more flexible and really figure out more intentional ways of supporting folks outside of just the systems that we're usually restricted within.
>> TIM FUCHS:  Great, thanks.
All right.
I know you all talked about subsidies and frankly I'm not sure when this ‑‑ I can't remember if this question was submitted before you all addressed this so I thought it wouldn't hurt to visit.  Jennifer is wondering if people are relying primarily on federal or also state and she is curious if anyone has managed to get HUD emergency solutions grant funds?
>> ANAYA ROBINSON:  I believe it was you that was walking through the rental subsidies your consumers were able to use, so do you want to take a ‑‑ do you want to answer that.
>> ANAYA ROBINSON:  Yeah.  We did have in Colorado state housing vouchers specifically for transition and diversion for our community that we were able to pretty fiercely advocate for a few years back to ensure that we had an option for support through transitions and diversion to get folks housed.  One of the really good things and I saw a few questions about this in the chat as well.  Because we have state housing vouchers, they work similarly to HUD but they also don't have to have the same restrictions for eligible as HUD housing vouchers.  So we're able to get our consumers access to these vouchers without them having to pass a background check which really increases the likelihood of folks who may otherwise not be able to obtain housing because they don't have access to the subsidy.  We can get them access to the vouchers and then it's just a lot of negotiation with landlords around background instead of trying to find apartments that rent‑wise don't exist.
So it's really increased options and opportunity for our consumers because of that lessened restriction around access.
>> TIM FUCHS:  Great, thanks.
All right.  Working my way down through these.
Angel is curious about the difference here.  Obviously there are a lot of carryovers or similarities with transitions and other relocations and diversions, right.  So many of the partnerships and challenges that you all described are reminiscent of that.  What about the pacing.  Have you all been slowed down because of the COVID environment?  How does this compare to your normal timing for transitions and relocations.  I'll come to you all in Pennsylvania first, Jodie or Misty, if you want to respond.
>> MISTY DION:  Initially I think it slowed us down quite a bit.  There were a couple of months that we received very little referrals for the transition program.  Just like I said, the sheltering in place, the barriers we noticed with communicating with the facility, all of that definitely slowed us down. 
I'm not sure if Anaya or Jodie has a different perspective.
>> ANAYA ROBINSON:  I think we experienced the same.  In the beginning it was pretty slow moving.  I think with more and more people knowing that this pilot exists, we have really seen an uptick in people reaching out to us to get in on the pilot.  And I think over all timelines of tradition, I think because of that flexibility I talked about before, and not necessarily worked within a bureaucratic system to transition folks, for the transitions themselves we've seen them generally move a lot faster than the speed with which we're able to transition people through a Medicaid program.  So in that regard, this has been a much quicker process for a lot of folks but I do agree with Misty that in the beginning it was a slow roll into something that luckily sped up for us.  But it was a little concerning in the beginning for a while there about whether or not we were every gonna be able to test this idea that we had that we thought was pretty good but needed to get to people so we could actually prove that it was pretty good. 
>> TIM FUCHS:  Great.  So Maria asked a question about access to caregivers, PAs nurses and she describes a situation in Ohio where they have been hampered by their availability of these folks.  We've seen the way this is ‑‑ COVID has impacted this.  Whether PA are COVID positive or may have been exposed to consumers.  So she is wondering how are you finding HHA which I assume is home health aids and nursing and getting them credentialed with their appropriate programs?  I'll add to that, how have your PAs and other support staff been impacted by this?  Has that been a big problem for you all or not?  Misty, do you want to respond first?
>> MISTY DION:  I'll let Jodie take this.  She directly handles that piece of it.
>> TIM FUCHS:  Great, thanks.
>> JODIE BANEY:  Hi, this is Jodie.  So being as we have a PAS agency as well that's been helpful.  I'm a nurse so that's definitely been beneficial and then partnering with other agencies has really been the key to it, not one agency can do it alone.  I think no matter what the staffing is right now during COVID, so having that partnership within the community and no matter what, we have seen the pandemic hit the home health side of things as well.  So that's why we continue to partner with multiple agencies.  It definitely is beneficial.
>> TIM FUCHS:  Great, thanks.
Is there an issue in Denver, Anaya.
>> ANAYA ROBINSON:  Historically during transitions, staffing has been one of the biggest issues in being able to more quickly move folks out of institutions.  And I think we identified that as a barrier early on when we were trying to build out this pilot and that's one of the reasons we wanted to create a really solid option for people to utilize our consumer‑directed models.  So in Colorado, the Nursing Practice Act is waived in both of our consumer‑directed service delivery models which means that our consumers can hire their own attendant and they don't have to be credentialed in the model that we're using most frequently in this pilot, those individuals will get hired on by an agency and trained by both the agency and the individual receiving services, and it comes with 24‑7 backup and nurse oversight.  So that's allowed us to tap into an employment pool that's really been left untapped historically and work with our partner organization to identify folks who are currently experiencing homelessness who want to be employed and want to provide these services to individuals and spend sometime introducing them to the folks we're transitioning and let them figure out if that feels like a good option and if it is, we get to move forward.  And get some folks hired and then get our consumers receiving the services they need in the hotel.
I think that's one side of it too.  We spend a lot of time talking our consumers through what all of their options are and making sure that they know which ways they can receive services and which models exist and how they access those.
So I think we've ‑‑ we still see some staffing issues for sure but I think we've really been able to create a model that alleviates that to a certain extent by using our consumer‑directed options and working with folks to identify individuals to hire who need employment and really want to be able to do this type of work and one of the things we've really been able to identify through that too is the number of people experiencing homelessness in our area or at least who previously were CNAs or nurses, their situation change and we've able to find people who still have the license to get on board with this pilot as well.  
>> TIM FUCHS:  Great.  Thanks.  
Misty, coming back to you, have you all been impacted by the changes in FEMA's emergency policy in regards to PAS, personal attendant services, during sheltering?  It's a good question from Todd.  I was wondering if that impacted you.
>> MISTY DION:  We were talking about that earlier.  We're watching it.  Right now we've used COVID funds for some of our relocation expenses and on we're setting ourselves up for once we run out of the funds, then we'll continue and work through our applications with FEMA for those category B and that's the guidance, I think Todd is mentions that I shared there.  We continue to request meetings with FEMA for additional guidance and hopefully we can get that soon.  But to this point, we've not received any funding from FEMA.  I'm not sure that FEMA has funded any relief for anyone in a long‑term care facility to this point.
>> TIM FUCHS:  Okay.  Thanks.
So Peggy is wondering ‑‑ we've talked a lot about funding.  What about the average cost.  Peggy is wondering what these moves have cost minus the cost of the hotel.
Have you all analyzed those costs?  Do you have a sense?  Anaya, I'll come to you.
>> ANAYA ROBINSON:  On average with the hotel costs including the caregivers' rooms and household setup and that side of things, it's been around a 3500 to $5,000 average costs per transition.  That's why it's been really helpful to create some funding streams to make sure we're not overusing any particular funding stream to fund this pilot.  But those costs obviously fluctuate as well depending on the individual and what they need for household setup.  How long they're in the hotel room but it's been right around that, 3500 to $5,000 average for most of our folks.
>> TIM FUCHS:  Okay great.  And that was with the hotel expenses; is that right? 
>> ANAYA ROBINSON:  Yeah, that includes the hotel expenses.  Not including the hotel expenses, it's probably just around 1500 per transition that we're expending outside of the hotel room costs.
>> TIM FUCHS:  Congratulations.  That's extremely cost‑effective.  What about for you all, Misty.
>> MISTY DION:  Our figures are slightly higher.  Although we are near that $5,000 average, we had some cases with individuals who were COVID positive and transportation and some of those other services increased it.  We also in the figures that we have, we've tried to allocate time for a nursing assessment and service coordination and added expenses into that.  So we were looking somewhere between 5,000 and 7500. 
With some of those cases especially when you look at COVID positive.
>> TIM FUCHS:  Got it.  Thanks.
We already talked about barriers.
Jose is curious about the new variants we're seeing.  So luckily there's early indicators that maybe these vaccines are going to be effective.  How does that factor into your planning here as COVID varies and we hear about some of these troubling variants, there could be a possibility we might need to ramp up these efforts.  Have you all had those conversations or do they factor into your planning?  I'll throw that out to the group to see if any of you want to comment on that.
>> ANAYA ROBINSON:  I think that's one of the reasons ‑‑ and we've had some of these limited conversations, but I think that's one of the reasons that we have really identified the need to continue to move forward with these programs and have really continued to try to identify more sustainable funding streams.  We know the CARES Act dollars run out in six months, and we know that the likelihood ‑‑ because we don't know what's going to happen in the future even with the vaccines, we know there's a high likelihood these programs are going to need to continue to exist for a while if not forever.  So I think that is something that we're taking into account and really trying to focus and Misty and I have talked about this a ‑‑ Misty and I have talked about this a lot.  There are some many people de‑escalating these type of programs because of vaccine rollout has started to ramp up more and more and I think we're both very aware that doesn't mean that this isn't going to continue to be an issue for our community especially in congregate settings.  So I think really keeping that top of mind is really helping drive us to continue to do this work and to figure out how to do it for as long as possible.
>> TIM FUCHS:  Absolutely.  It's a great point to end on.  I think it's also ‑‑ feeds into this conversation around other webinars that we talked about in May on or congregate settings and the fact that is going to continue to be an issue regardless of what happens with COVID.  And, of course, transitioning and community settings being such a paramount issue.  
Well, we are here at 429 at least on the east coast.  Thanks to everybody that joined and submitted questions today.  We got through almost all of them.  We got really close but you need to make sure we end on time.  Look, I can't thank our panelists enough.  Misty, Jodie, Anaya, again I know you guys are slammed and the fact you're willing to take time out of your schedule to share what you all have learned and what you have built, I really appreciate it.  I thank you all for your work on this.  You didn't miss a beat.  You recognized this was life or death and you said what can we do and you ran with it and I think you need to be commended for that so thank you for your work.
I want to mention a couple of things just logistics before we close.  Remember we have the recording so if you want to revisit it or share it with a colleague, this will be up on IL‑NET's on demand page on ILRU's website within 48 hours usually sooner.  We'll post to archive of the presentation with captioning, the materials which are the PowerPoint that you're looking at, and the chat history.  And then we're not going anywhere so if you have other questions that come up, feel free to use me as a point of contact.  I'd love to hear from you.  If you have questions about content, or it can be as peripheral as you want to, this is a technical assistance project so I'm happy to answer any questions you have about anything related to today's presentation or operating the CIL.  So throw it at me.  Do fill out this evaluation.  I'm sharing my screen so you can't click on that link right there.  But when I close the webinar this evaluation will pop up on your computer.  If you would take a minute to fill that out, I would really appreciate it.  This same link was sent to you in the materials e‑mail.  So assuming that you registered at least an hour before the webinar, you should have received the materials e‑mail from NCIL with the content for today's webinar and that link was in there.  If you don't see that, let me know and I'll forward it to you.
Again, I want to thank all of you for joining us.  I want to thank our panelists again.  I hope you all have a wonderful afternoon and we'll talk to you soon.  Bye‑bye.