Nursing Facility Transition and Diversion

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)
• [phone]
• 5. Access to Housing

5
Key Issues for Successful Transition

1. Positive reputation with agencies
2. History of utility bills paid on time
3. 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)
• [phone]

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 [phone]
• 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/director
  y05-06.pdf
• Mediation
• A listing of Centers for Dispute Resolution in
  Michigan
• http//courts.michigan.gov/scao/resources/other/cd
  rpcenters.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_216
  07-31837--,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