transition and diversion - texas health and human … staff familiar with the individual’s needs...
TRANSCRIPT
Transition and Diversion for Individuals with IDD Residing in or
Diverting from Nursing Facilities August 2017
Introductions and Objectives
• Introductions • After successful participation, participants will be able to: o describe the critical steps in the
transition/diversion process; and
o summarize required pre-move and follow-up activities for someone who has relocated or diverted from a nursing facility to a community living option.
2 9/6/2017
Data on Transitions and Diversions Fiscal years 2014-15 1. 145 individuals successfully transitioned
from nursing facilities (NFs). 2. 140 individuals successfully diverted from NF
placement.
Fiscal years 2016-17 (as of 5/31/17) 1. 353 individuals successfully transitioned
from NFs. 2. 284 individuals successfully diverted from NF
placement.
3 9/6/2017
Service Planning Team (SPT)
SPT Membership: 1. Individual 2. Legally authorized representative (LAR), if
applicable 3. Service coordinator 4. NF staff familiar with the individual’s needs 5. Persons providing specialized services for the
individual 6. If a community provider is selected, then a
representative from the provider 7. Relocation specialist, if the individual has
expressed a desire to transition 8. Other persons invited by the individual/LAR
4 9/6/2017
Role of Service Planning Team (SPT) • The SPT must ensure an individual in
an NF, regardless of whether there is an LAR, participates in the SPT to the fullest extent possible.
• The SPT develops an Individual Service Plan (ISP) using Form 1041.
• The SPT ensures implementation of and monitors all specialized services identified in the ISP.
• The SPT ensures the ISP is integrated into the NF’s plan of care.
5 9/6/2017
Transition Phases
Phase I – Education and Exploration of Community Settings/Community Living Options (CLO). Every individual residing in an NF receives CLO every six months. Phase II – Identifying the Individual’s Needs for Community Living Phase III – Transitioning from the NF
6 9/6/2017
Individual Service Plan (ISP) + Transition Phase I & II
7 9/6/2017
8 Page 8
September 1, 2014
I want to move from the nursing facility into the community. 9
September 1, 2014
10
• Denise and Tammy participated in a quarterly Provider Fair last month that was sponsored by Texas Local Authority and have reconsidered exploring community living options. Both visited 3 different community settings in town— an ICF/IID group home setting, an HCS foster care setting, and an HCS 3-person group home. Denise’s preference is to live in a 3-person group home in which she can have her own bedroom. SC and Tammy will continue to support Denise's exploration of area providers so that she may make an informed choice.
• • Service Coordinator will work with the Continuity of Care coordinator at Texas Local Authority to request an NF-to-HCS transition slot. • • Denise visited her gastroenterologist during the quarter. The gastroenterologist stated her g-tube seems to be adequately supporting her nutritional
needs and no changes were recommended. Denise states that she remains satisfied with the medical services related to her g-tube care and nutrition related needs.
• • The SC authorized employment assistance because transportation has been secured. An Action Plan was developed in today's SPT meeting. • • Denise shared that she was able to send three letters to friends and made a phone call to her cousin during the quarter. She stated that she is satisfied
with the supports from the NF staff and the service coordinator and felt that she was able to meet her outcome for this quarter. • • Denise was happy to discover that she can access transportation. She stated that she is satisfied with her supports so far and feels that she is
progressing toward her outcome of getting a job as a receptionist. • • The service coordinator has been unable to locate a neurologist in the area who will accept Medicaid and does not have a long waiting list for new
patients. Denise stated that she is satisfied with the Service Coordinator's efforts, however she does not feel that she is making any meaningful progress toward obtaining neurology care, locally; the SPT concurred.
• • Service Coordinator verified that PT sessions have occurred as planned via review of NF's record. Denise shared that she is satisfied with her PT services and that she and Tammy feel it is helping her meet her outcome of maintaining her strength and endurance in her upper/lower limbs.
• • A PT assessment was conducted on August 15, 2014, and a customized power wheelchair was recommended for Denise. Health First Services visited Denise on August 27th and took measurements. The new chair will have a customized insert and a reclining feature that should minimize pressure points on Denise’s skin and increase her comfort level. Denise stated that she is satisfied with the PT Assessment and feels that she is progressing toward her outcome of being able to ambulate more independently.
• • Denise accessed OT services as scheduled during the quarter according to record review. Tammy stated, and the therapist concurred, that Denise is maintaining her ability to grasp objects. Denise stated that she is satisfied with her OT sessions and feels that she is progressing toward her outcome.
• • An assessment by a speech therapist for a communication device is scheduled for October 3rd. Denise wants a device with a laser pointer system. Denise expressed dissatisfaction with the amount of time it has taken to obtain the assessment, but she feels that finally, progress is being made to help her communicate more readily with people.
• • A swallow test was completed by a speech therapist July 27th. It was determined Denise continues to be unable to take food or drink by mouth. Although Denise is disappointed in the results, she and Tammy were not surprised. Denise reports that she is satisfied with the service and its results.
Linn Johns
Page 11
I want to move from the nursing facility to the community.
August 27, 2014
Contact and assist the Continuity of Care Coordinator in obtaining an HCS Slot for Denise.
Support Denise's exploration of available HCS Providers.
Assist the Enrollment Service Coordinator in processing an HCS enrollment for Denise.
September 1, 2014
Originally Denise wanted to remain in the NF. Since that time, both Denise and Tammy, her sister, have reconsidered and are interested in Denise pursuing community placement. A CLO was completed because they were interested in moving to the community. Service Coordinator will support Denise's progression to Phase II of the Transition Plan, effective today, Sept. 1, 2014.
Linn Johns 13 Linn Johns
HCS Linn Johns September 10, 2014
Denise and Tammy already interviewed two providers and visited several community living settings. They are in the process of selecting a provider with a group home in NW Austin.
Denise and Tammy October 23, 2014
15
Individual Service Plan (ISP) and Transition Plan Phase III
16 9/6/2017
Denise Doe 12344321 November 10, 2014
Home Life Services
January 15, 2015
w/c accessibility: doors, ramps, baths, shower, vehicle Shower Chair Specialized mattress Hoyer Lift Trained staff: g-tube feeding, bathing, 2 person/mech trfr
HLS, Prog Director HLS, Prog Director
HLS, Prog Director HLS, Prog Director HLS, Prog Director
17
14
14
14
Home Life Services Service coordinator NA (sister manages) Empire NF, DON
Empire NF, DON
Empire NF, DON
Empire NF, DON
Empire NF, Soc. Wkr.
Empire NF, DON
18
N/A
Denise’s television Denise’s communication device
Home Life, Program Director
Tammy, sister Home Life, Program Director
January 20, 2015 January 20, 2015 February 15, 2015
January 22, 2015 (January 15 + 7 calendar days)
March 1, 2015 (January 15 + 45 calendar days)
April 15, 2015 (January 15 + 90 calendar days)
19
Pre-Move Site Review Instrument
20 9/6/2017
Page 21
Denise Doe 12344321 January 15, 2015 January 10, 2015
Home Life Services Angela Hernandez 512-458-9656
HCS 8724 Burnet Road, Austin, TX 78758 512-444-3289
4511 Valley Drive, Austin, TX 78759 512- 655-9877
Angela Hernandez (provider), Patricia Green (SC), and Tammy Johnson (sister)
LIDDA Pre-Move Site Review Instrument
22 28
23
Patricia Green January 10, 2015 Angela Hernandez January 10, 2015
23
Post-Move Monitoring Checklist
24 9/6/2017
25 25
Denise Doe 12344321 Patricia Green 01/15/2015 02/18/2015
Home Life Services Angela Hernandez 512-458-9656
HCS 8724 Burnet Road, Austin, TX 78758 512-444-3289
4511 Valley Drive, Austin, TX 78759 512- 655-9877
Angela Hernandez (provider)
26 26
Denise’s television Denise’s communication device
Documentation present Visible inspection Visible inspection
01/20/2015 01/20/2015 02/15/2015
The manufacturer has reported a shipping delay for Denise’s communication device. Its arrival is anticipated by March 3rd. There is minimal adverse impact. A staff member created a simple picture board for Denise to use in the meantime. Denise understands the reason for the delay and is looking forward to receiving her device.
27 Page 27
The Hoyer lift is not functioning properly. The provider has scheduled repairs. There Is adequate staff to perform a two-person transfer for Denise. No adverse impact.
Noticed a trail of ants in Denise’s bathroom SC will speak with Home Life Program and kitchen Director to report the problem.
Patricia Green
Patricia Green 02/18/ 2014
29
Request for Adult NF HCS Transition Slot Form 1046 An individual is eligible for this targeted Home and Community-Based Services (HCS) waiver slot if the individual:
is at least 21 years of age; currently resides in an NF; was not admitted to the NF for
rehabilitative purposes; is able to transition to community living
within 90 days; has a diagnosis meeting HCS eligibility
criteria; has received an oral and written
explanation of available community programs, services, and supports; and
has expressed a desire and preference for HCS.
20 9/6/2017
Page 31
Request for Nursing Facility Diversion (HCS) Form 1047
For an individual with ID/DD, who is at imminent risk to an NF or at risk of a long-term stay at an NF, the LIDDA is responsible for completing a PL1 and PE before requesting a NF diversion slot.
22 9/6/2017
Request for Nursing Facility Diversion (HCS) Form 1047 (cont.)
To be eligible for an HCS NF diversion slot, the LIDDA's diversion coordinator must document:
the individual has a diagnosis meeting HCS diagnostic eligibility criteria, including ICF Level of Care (LOC)*;
the current PASRR Evaluation indicates the
individual's needs can be met in the community (Section F); and
other adequate and appropriate community
resources, excluding community ICFs/IID or state supported living centers, are unavailable to meet the individual's needs.
The diversion coordinator then submits a completed Form 1047 to HHSC.
23 9/6/2017
Special LOC VIII HCS Eligibility Criteria for NF Residents
LOC VIII Eligibility
(B) Individual has been determined by DADS: (i) to have intellectual disabilities or a related condition; (ii) to need specialized services; and (iii) to be inappropriately placed in a Medicaid certified
nursing facility
*Rules governing HCS Program 40 TAC, Chapter 9, Subchapter D
§9.155(a)(2)(B)
24 9/6/2017
Page 35
35
Thank you Mendy Blevins, M.A., CTCM
IDD Services
36 9/6/2017