Money Follows the Person

 

Money Follows the Person (MFP) is a demonstration program that helps Montana shift its long-term care system by reducing the use of institutionally based services and increasing the use of home and community based services (HCBS). MFP is focused on helping individuals transition from in-patient facilities to the community.

MFP Vision: Create a sustainable system that supports community options as a first choice for individuals needing long-term care services.

Explore how the MFP Demonstration Project helps improve long-term care in Montana, giving individuals the freedom to live independently, choosing where they live and how they receive services.

Overview

The MFP Project began as a five-year grant award to shift Medicaid Long-Term Care from its emphasis on institutional care to home and community-based services. MFP is the longest running demonstration project in the history of Medicaid and has resulted in the transition of thousands out of institutions back in to the community. Studies show that MFP participants are happier, and healthier when they reside in the community.

Montana’s MFP Project

Montana was granted 9.3 million dollars in 2014 and partners with three waiver programs (SDMI, DD, and Big Sky) in its goal of transitioning individual Medicaid recipients back to the community from an institutional setting.

Montana MFP Goals

  • Increase the use of home and community-based services.
  • Increase expenditures in the home and community-based services programs.
  • Decrease the use of institutional long-term care services.
  • Increase the utilization of Self-directed services in home and community-based programs.
  • Increase the availability of affordable, accessible housing.
  • Demonstrate the effectiveness of transition/demonstration services.

Demonstration Services

MFP assists participants with their transition from an institutional setting through the provision of demonstration and transition services as outlined below:

  • When necessary, provision of the first month rent and deposit.
  • Assistance with past due rent and utility bills/deposits.
  • Household goods and services to include (limited) basic household furnishing, bedding, kitchenware, etc.
  • Environmental and vehicle modifications
  • Peer Support
  • Information Technology
  • Overnight supports
  • Medication Management Technology

Referrals

Referrals are generally made by discharge planners, nursing staff, social workers, case managers, ombudsmen. Individuals may self-refer to this program. Referrals can be made online

To participate in Montana’s Money Follows the Person (MFP) program, individuals must meet specific residency, Medicaid, waiver, and level-of-care criteria that ensure a safe, successful transition from institutional care to community living. The program serves older adults, as well as adults and children with physical or developmental disabilities or a serious mental illness.

Core Criteria

  • Residency: Eligible participants have resided in a qualifying long-term care facility for at least 60 consecutive days.
  • Medicaid coverage: Care must have been covered by Medicaid for at least one of those 60 days.
  • Waiver participation: Participants must participate in one of Montana’s Waiver Partner Programs.
  • Appropriateness for waiver: Participants must be determined appropriate for one of the waiver partner programs.
  • Institutional level of care (pre- and post-transition): Participants must meet the institutional level-of-care criteria before transition and continue to meet those criteria after moving to the community.
  • Target populations: Older adults, and adults and children with physical and/or developmental disabilities or a serious mental illness.
  • Ongoing case management: After transitioning, participants meet regularly with their case managers throughout their 365-day participation period

Partner Waiver Programs

  • Big Sky Waiver: Elderly and Physically Disabled
  • SDMI Waiver: Serious Disabling Mental Illness
  • DD Waiver: Developmental Disabilities

Qualified Housing Settings

  • Private home: Owned or leased by the participant or a family member
  • Apartment: Individual lease, secure access, and separate living, sleeping, bathing, and cooking areas under participant/family control
  • Small group home: Community-based residential setting with a maximum of four unrelated residents (excluding caregivers and personal attendants)

Supplemental services are short-term services to support an MFP participant’s transition from institutional living to community living, not otherwise allowable under Montana Medicaid. Montana MFP covers the following supplemental services while an individual is living in an institutional setting but is in the process of moving into the community. All services must be paid for and received prior to moving into the community home.

Clothing Grant: MFP participants sometimes leave their institutional setting in hospital scrubs only. This clothing grant allows participants to obtain essential clothing with the goal of community integration.

Pantry Stocking: This allows participants to obtain a baseline of nutritional needs for when they arrive in their new home. The pantry stock ensures participants' nutritional needs are met upon moving. Food banks, while an important resource, are not available in all areas of the state. All MFP participants are encouraged to apply for SNAP benefits after moving into the community.

Transportation: Transportation is designed to facilitate on-site visits to community housing, which may include visits to community-based housing entities.

Simple Home Repair: This service preserves existing housing while ensuring safety through the provision of minor repairs. It is limited to participant or participant family-owned properties.

Home Modifications: Modification of the home environment maximize participant independence and decrease barriers.

Assistive Technology: This services increases independence by providing assistive technology, which may include items ranging from medication dispensers to temperature control and door lock/unlock systems for participants with disabilities requiring such intervention. 

Occupational Therapist Assessment: An occupational therapist conducts a home visit with the MFP participant and the transition team while the participant still lives in the institutional setting. The assessment identifies needed modifications and/or equipment (including assistive technology) to increase the participant's independence and safety. 

Vehicle Modification: This service allows for modifications to an individual's previously purchased vehicle. Modifications are made specific to the vehicle and the individual's needs. A professional completes the modifications, requiring estimates and receipts. This ensures availability of a modified vehicle prior to and upon participant discharge.


 

Please click the link below to submit an MFP referral.

Submit an online secured form

April Staudinger
Project Director
(406) 439-6870
AStaudinger@mt.gov

Haley Horn
State Transition Coordinator/Grant Specialist
Haley.Horn@mt.gov

Morgen Heckford
Housing Specialist
Morgen.Heckford@mt.gov

Transforming Lives with the Money Follows the Person

The MFP program helps individuals transition from institutional settings to community living, enhancing their independence and quality of life. These success stories highlight the transformative impact of the MFP program on the lives of participants.

Success Story 1: From Assisted Living to Independence

A 31-year-old man from Missoula, diagnosed with cerebral palsy and spastic quadriplegia, had lived in assisted living facilities (ALF) for years. When his ALF closed in April 2023, he was transferred to a skilled nursing facility where he experienced depression and suicidal thoughts.

With the support of the MFP transition team, he secured an accessible housing unit through the Missoula Housing Authority and moved into his own apartment on September 4, 2024. With caregivers, a ceiling-lift system, and an automatic door opener, he now thrives in community living.

"I really like where I am, big switch from where I was. I go to the community center where I have been a part of two movies both in front and behind the camera. And the best part, I haven’t had one suicidal thought in two months. Tomorrow, I see my doctor about getting off one of my anti-depressants.”

Success Story 2: Homecoming and Independence

A 43-year-old woman was residing in her home with her roommate/caregiver when she was hospitalized due to a foot infection. After a skilled-nursing stay, she was discharged home through the assistance of MFP and BSW. With goods and services to set up her household and the installation of a ramp, she now moves independently in and out of her home and is thriving.

She expressed her gratitude, stating, "When I was in the nursing home, I thought … I’m going to die here. And now, now I’m home.”

Success Story 3: Returning to Community Living

A 65-year-old man, an enrolled member of the Blackfeet tribe, sustained a traumatic brain injury due to a motor vehicle accident as a teenager. He relied on his spouse for care, but, unfortunately, the care provided was inconsistent and did not adequately meet his needs.

He was discovered in ailing health and was moved to a nursing home in October 2022. By May 2024, he transitioned to community living at an ALF in Polson. His family visits often, and he enjoys fishing on Flathead Lake.

"Over there it wasn't that great, and you couldn't go outside … here you can, and I water the garden for a while … here the boss lady will come help you fix your Wi-Fi, when down there (NF), you got to wait for IT, and they don't come for long times. I like this food, its good too and I get to have my room to myself and don't have to be quiet with my games.”