Nursing Facility Transition and Diversion

Module 5:

Transition, Follow-up, Tools and Resources

Transition and Follow-up Overview

Initiating the Transition

Housing obtained Three weeks prior to move Two weeks prior to move One week prior to move Day before move Day of move

Follow-up

Transition example

Transition and Follow-up

Initiating the Transition

Housing obtained

Set a discharge date Pay security deposit and first month rent Review PCP Furniture list and preferences Household needs

Transition and Follow-up

Three weeks prior to the actual move:

Ensure plans have been made for appropriate supports and services including

MiChoice Waiver/Medicaid Home Help Visiting Physicians/Doctor Schedule Home Evaluations

Home Modifications Durable Medical Equipment

Transition and Follow-up

Two weeks prior to move, ensure:

Purchase of necessary furniture and household items

Banks are visited in the areaHome delivered meals, if needed

Transition and Follow-up

One week prior to move, ensure

Pharmacy is foundUtility companies are calledConsumer is actively engagedCommunication with social workerCommunication with Waiver team Information sheet developed

Transition and Follow-up

Day before move

Purchase food and other necessitiesCommunicate with social worker

Prescriptions DME Discharge time Transportation

Transition and Follow-up

Day of Move

PrescriptionsMeet consumerWaiver teamHomecare staffDurable Medical Equipment

Transition and Follow-up

Follow-up

The next dayThe next monthThe next year

Transition example

Gary

Had a strokeAffected his speech and cognitive

abilitiesParalysisUnable to handle financesNeeded a conservator

Tools and Resources for Transition

Handouts:

Resource Planning Overview-HO#1General Timelines for Transition-HO#2Transition Checklist-HO#3Accessing Housing-HO#4

Tools and Resources for Transition

Nursing Facility Transition Services-HO#5

Civil Monetary Penalty Funded Nursing Facility Transition Codes-HO#6

Tools and Resources for Transition

Nursing Facility Transition Notice-HO#7

Nursing Facility Transition Notice Report Fields-HO#8

Nursing Facility Transition Notice Example-HO#9

Tools and Resources for Transition

Civil Monetary Penalty Funded Nursing Facility Transition Expenditure Report-HO#10CMP Funded NFT Expenditure Report

Fields-HO#11

Nursing Facility Transition Frequently Asked Questions-HO#12

Resources

Identify the following resources in your own community: Waiver Agents Second Hand and Thrift Stores

Furniture Household Items

Food Pantries Housing Providers Home Care and Visiting Physicians Banks and Credit Unions Pharmacies that Deliver Durable Medical Equipment Providers Home Modification Providers Occupational Therapists Home-delivered Meal Providers