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) 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)

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 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

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  Independence  Financial  Safety  Relationships  Care Needs

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

Financial Social Security  Social Security Administration (800) 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 complexes  On site visits  Rental information  Utility information  Criminal 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: Mental Health  A listing of all of the Community Mental Health Agencies: Mediation  A listing of Centers for Dispute Resolution in Michigan: Financial Education  For information on the local sites for Building Your Financial Future which provides financial education for people with disabilities go to:

Resources Guardianship  For more information about Michigan Protection and Advocacy Services go to their website: Housing Information  Directory of Subsidized Housing:  Corporation for Supportive Housing: Social Security Administration website: Food Stamps  A Listing of local Department of Human Services Offices can be found by going to 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: _ ,00.html _ ,00.html You can get to this link by going to 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