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 area  Home delivered meals, if needed

Transition and Follow-up One week prior to move, ensure  Pharmacy is found  Utility companies are called  Consumer is actively engaged  Communication with social worker  Communication with Waiver team  Information sheet developed

Transition and Follow-up Day before move  Purchase food and other necessities  Communicate with social worker Prescriptions DME Discharge time Transportation

Transition and Follow-up Day of Move  Prescriptions  Meet consumer  Waiver team  Homecare staff  Durable Medical Equipment

Transition and Follow-up Follow-up  The next day  The next month  The next year

Transition example Gary  Had a stroke  Affected his speech and cognitive abilities  Paralysis  Unable to handle finances  Needed a conservator

Tools and Resources for Transition Handouts:  Resource Planning Overview-HO#1  General Timelines for Transition-HO#2  Transition Checklist-HO#3  Accessing 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#10  CMP 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