nursing facility transition and diversion module 4: nuts and bolts of transition
TRANSCRIPT
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