Nursing Facility Transition and Diversion Module 4: Nuts and Bolts of Transition.

Nursing Facility Transition and Diversion

Module 4:

Nuts and Bolts of Transition

Overview

Key Issues for Successful Transition

Initial Meeting and Assessment Person-Centered Plan Housing Transportation Other Issues

Key Issues for Successful Transition

1. Motivation

2. Length of Nursing Facility Stay

3. Natural Supports

Key Issues for Successful Transition

4. Eligibility for Support

Michigan Protection and Advocacy Services (MPAS)

(800) 288-5923

5. Access to Housing

Key Issues for Successful Transition

6. Positive reputation with agencies

7. History of utility bills paid on time

8. Strong credit

Key Issues for Successful Transition

9. Family support and unity

10. No substance abuse history/behavior or strong record of recovery

11. Mental Health support

Key Issues for Successful Transition

12. Guardianship

Michigan Protection and Advocacy Services (MPAS)

(800) 288-5923

Initial Meeting and Assessment

Purpose Allow a 3 to 4 hour time slot for

transition staff Introductions Discuss the transition program Releases of Information

Responsibility, Medical

Initial Meeting and Assessment

Working for an Area Agency on Aging

Working for a different organization Importance of Level of care and financial

status

Identify financial resources

Initial Meeting and Assessment

Obtain copies of chartHistory and PhysicalMedication listAny Psychiatric evaluationsPast week physician, nurses, OT, PT and

social workers notesAdmission Face Sheet

Discuss basic housing needs

Initial Meeting and Assessment

12 Issues related to successful transition

Veteran status

Initial Meeting and Assessment

Discuss Person-Centered Planning (PCP)

What it is Person-Centered Planning provides an opportunity for

the consumer, his/her advocates, family, friends and other chosen allies such as professional staff to get a clear sense of the life goals and desires of the consumer including plans to transition back to the community.

Who they want to help with plans (allies) What topics they do and do not want to discuss Meeting date and time

Person-Centered Planning

Dreams

Nightmares, concerns, or fears IndependenceFinancialSafetyRelationshipsCare Needs

Person-Centered Planning

Goals and steps to achieve goals

Assign tasksConsumer, family, staff, friendsSet timelinesSet up next meeting date

Financial

Social Security

Social Security Administration (800) 772-1213

Food Stamps

Housing

If consumer already has home

Make a home visit

Accessibility and safety issues Household needs Durable Medical Equipment (DME) needs

Housing

Subsidized Housing Supported Housing If housing is needed:

Call apartment complexesOn site visitsRental informationUtility informationCriminal background checks

Transportation

Bus Availability

Paratransit application

From nursing facility to own home or apartment

Resources

Substance Abuse A listing of substance abuse regional coordinating agencies:

http://www.michigan.gov/documents/CA_Contact_List_123511_7.pdf

Mental Health A listing of all of the Community Mental Health Agencies:

http://www.macmhb.org/directory/directory05-06.pdf

Mediation A listing of Centers for Dispute Resolution in Michigan:

http://courts.michigan.gov/scao/resources/other/cdrpcenters.pdf

Financial Education For information on the local sites for Building Your Financial Future

which provides financial education for people with disabilities go to: http://www.copower.org/AT/BYFFlocal.htm

Resources Guardianship

For more information about Michigan Protection and Advocacy Services go to their website: www.mpas.org

Housing Information Directory of Subsidized Housing: http://www.mshda.info/housing/ Corporation for Supportive Housing: 810-229-7712

Social Security Administration website: www.ssa.gov

Food Stamps A Listing of local Department of Human Services Offices can be

found by going to www.michigan.gov/dhs and clicking on County Offices on the toolbar on the left side of the page.

Resources Transportation

A listing of all public transit providers in Michigan can be found at the MDOT website:

http://www.michigan.gov/mdot/0,1607,7-151-9625_21607-31837--,00.html

You can get to this link by going to www.michigan.gov/mdot select doing business from the list on the left side, select Passenger Transportation on the left side of the page, and then select Public Transit Providers