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Nursing Facility Transition and Diversion

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

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Nursing Facility Transition and Diversion

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

  2. Overview • Key Issues for Successful Transition • Initial Meeting and Assessment • Person-Centered Plan • Housing • Transportation • Other Issues

  3. Key Issues for Successful Transition 1. Motivation 2. Length of Nursing Facility Stay 3. Natural Supports

  4. Key Issues for Successful Transition 4. Eligibility for Support • Michigan Protection and Advocacy Services (MPAS) • (800) 288-5923 5. Access to Housing

  5. Key Issues for Successful Transition • Positive reputation with agencies • History of utility bills paid on time • Strong credit

  6. Key Issues for Successful Transition • Family support and unity 10. No substance abuse history/behavior or strong record of recovery • Mental Health support

  7. Key Issues for Successful Transition • Guardianship • Michigan Protection and Advocacy Services (MPAS) • (800) 288-5923

  8. 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

  9. 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

  10. Initial Meeting and Assessment • Obtain copies of chart • History and Physical • Medication list • Any Psychiatric evaluations • Past week physician, nurses, OT, PT and social workers notes • Admission Face Sheet • Discuss basic housing needs

  11. Initial Meeting and Assessment • 12 Issues related to successful transition • Veteran status

  12. 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

  13. Person-Centered Planning • Dreams • Nightmares, concerns, or fears • Independence • Financial • Safety • Relationships • Care Needs

  14. Person-Centered Planning • Goals and steps to achieve goals • Assign tasks • Consumer, family, staff, friends • Set timelines • Set up next meeting date

  15. Financial • Social Security • Social Security Administration (800) 772-1213 • Food Stamps

  16. Housing • If consumer already has home • Make a home visit • Accessibility and safety issues • Household needs • Durable Medical Equipment (DME) needs

  17. Housing • Subsidized Housing • Supported Housing • If housing is needed: • Call apartment complexes • On site visits • Rental information • Utility information • Criminal background checks

  18. Transportation • Bus Availability • Paratransit application • From nursing facility to own home or apartment

  19. 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

  20. 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.

  21. 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

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