1. New Community Opportunities Center at ILRU – Independent Living Research Utilization 0 Nursing Home Transition 4-Part Webinar Series Part 4: Following Up After the Move October 12, 2011 Presented by: Bruce Darling New Community Opportunities Center at ILRU Presents…

2. New Community Opportunities Center at ILRU – Independent Living Research Utilization 1 Nursing Home Transition 4-Part Webinar Series Part 4: Following Up After the Move October 12, 2011 Presented by: Bruce Darling New Community Opportunities Center at ILRU Presents…

3. New Community Opportunities Center at ILRU – Independent Living Research Utilization 2 Purpose of the Project This presentation is part of a series of trainings and other activities provided to the IL field by the New Community Opportunities Center at ILRU. The project’s purpose is to assist CILs in developing self-sustaining programs that support community alternatives to institutionalization for individuals of any age, and youth transition from school to post-secondary education, employment, and community living.

4. New Community Opportunities Center at ILRU – Independent Living Research Utilization 3 Community Alternatives Project Team ILRU’s partners and collaborators in the community alternatives activities include Utah State University, Center for Persons with Disabilities National Council on Independent Living Suzanne Crisp, national community alternatives expert Association of Programs for Rural Independent Living Michele Martin, Social Media Consultant

5. New Community Opportunities Center at ILRU – Independent Living Research Utilization DONE! No so fast… The person has transitioned into the community. We’re done. Right? No.

6. New Community Opportunities Center at ILRU – Independent Living Research Utilization We will review… Post Transition Responsibilities Post Transition Activities for Each of the Components in a Transition Plan Common Post Transition Issues or Concerns Available Check Lists

7. New Community Opportunities Center at ILRU – Independent Living Research Utilization Post Transition Responsibilities Maintain contact based on the individual’s needs and preferences Provide empathy Be aware of and prepare for emotional challenges Assist the individual in looking to the future

8. New Community Opportunities Center at ILRU – Independent Living Research Utilization Get Folks Involved! Get the individual involved in your Center for Independent Living and local disability rights community The person can provide peer support to others making the transition The person you have assisted in transitioning has a unique perspective that needs to be heard by policy makers –Consolidated Plan for Housing –State’s Olmstead Planning Process

9. New Community Opportunities Center at ILRU – Independent Living Research Utilization Document Your Success! Report on your work in the Center’s Annual Report Documentation can help change the system. New York State Centers track the savings associated with our transition work

10. New Community Opportunities Center at ILRU – Independent Living Research Utilization Post Transition Support and Advocacy Review and modify the Independent Living Plan as needed Assist individuals in getting their needs met Advocate on their behalf The following slides review “next steps” for each of the components of the Transition or Independent Living Plan

11. New Community Opportunities Center at ILRU – Independent Living Research Utilization Housing Is the housing appropriate to the individual’s needs? Have the needed modifications all been completed and do they meet the person’s needs? Are there additional modifications still needed? Is the rent being paid? Has rental assistance and/or subsidies been obtained and are the payments working as expected? 10

12. New Community Opportunities Center at ILRU – Independent Living Research Utilization Housing, cont’d. If there is a roommate, is this working out? Are additional furnishings needed? 11

13. New Community Opportunities Center at ILRU – Independent Living Research Utilization Personal Assistance If the individual has personal assistants, how is this working out? Are the hours of assistance sufficient? Are the persons needs being met? Is the person able to provide adequate direction to the personal assistant(s)? Does the individual need additional information on how to effectively manage personal assistants? 12

14. New Community Opportunities Center at ILRU – Independent Living Research Utilization Assistive Technology Did the individual receive the assistive technology devices specified in the Transition Plan? Are the devices working properly and is there a plan for them to be serviced if needed? Is there additional assistive technology that might further support the individual to live in the community? 13

15. New Community Opportunities Center at ILRU – Independent Living Research Utilization Health Care Have all medical needs been addressed by appropriate health care professionals? Have all health care appointments been made and kept? Has all durable medical equipment such as transfer benches, wheelchairs, commodes, etc. been obtained and is it working properly? 14

16. New Community Opportunities Center at ILRU – Independent Living Research Utilization Mental Health Services/Supports How is the person handling the stress of the transition? Are there any mental health needs that should be addressed? Does the individual acknowledge these needs and does she want assistance? How would the individual prefer to have these needs addressed? 15

17. New Community Opportunities Center at ILRU – Independent Living Research Utilization Mental Health Services/Support, cont’d. Has the transition improved the individual’s mental health status and reduced the need for medications or treatment? Is the person having any issues with post- traumatic stress? 16

18. New Community Opportunities Center at ILRU – Independent Living Research Utilization Addiction Services and Supports Are there any needed services or supports needed related to an addiction? Does the individual acknowledge these needs and does she want assistance? What do I do if the person has begun drinking or using drugs again? 17

19. New Community Opportunities Center at ILRU – Independent Living Research Utilization Transportation Is the plan meeting the individual’s transportation needs? Is accessible transportation available in the local area? Is the individual making use of what is available? Is there a need for training on how to use the transportation system? 18

20. New Community Opportunities Center at ILRU – Independent Living Research Utilization Volunteering Does the individual have volunteer activities? Is the individual interested in volunteering? Are any supports needed to assist the individual with this? Are there any specific barriers that need to be addressed, like access to personal assistance outside the home or transportation? 19

21. New Community Opportunities Center at ILRU – Independent Living Research Utilization Education and Employment Does the individual want to be employed? Full- time? Part-time? Does the individual have a job? If not, what efforts is the individual making to find employment? Are other supports needed to assist the individual with his search for employment? 20

22. New Community Opportunities Center at ILRU – Independent Living Research Utilization Family and Friends Have family and/or friends been involved in the individual’s transition? Do family or friends have any questions or concerns about the transition? If family or friends provide supports as part of the plan, is this effective at meeting the individual’s needs? Do the informal caregivers need any support? Are they at risk of “burn out”? 21

23. New Community Opportunities Center at ILRU – Independent Living Research Utilization Social, Faith, and Recreation What recreational activities or hobbies is the individual participating in or would like to be involved in? What support is the individual receiving for social, faith, and recreational activities? If he chooses, is the individual involved in the religion of his choice? Has the person been supported in reintegrating into a religious service of his choice? 22

24. New Community Opportunities Center at ILRU – Independent Living Research Utilization Finances You may need to assist the consumer in paying the first month's bills. If you are not, are the bills being paid on time? Does the budget meet the person’s needs? Do you need to work with the person to adjust budget? 23

25. New Community Opportunities Center at ILRU – Independent Living Research Utilization 24 Questions and Answers

26. New Community Opportunities Center at ILRU – Independent Living Research Utilization Common Post Transition Issues The person who transitioned may: have difficulty managing their personal assistance be taken advantage of by workers, attendants or others (financially or otherwise) be threatened with re-institutionalization be reluctant to seek medical care or hospitalization, particularly if that was the way they were institutionalized 25

27. New Community Opportunities Center at ILRU – Independent Living Research Utilization Things to Watch For Potential medical complications identified in the Transition Plan Change in mental status or psychological status Change in physical condition or abilities Change in the cleanliness of the apartment or home Financial difficulties 26

28. New Community Opportunities Center at ILRU – Independent Living Research Utilization Addressing Issues Provide information to the individual for informed decision-making Use the Safety Planning process to assist the individual in identifying solutions Support the individual without judging Be clear that you are available to assist or advocate as needed in the future 27

29. New Community Opportunities Center at ILRU – Independent Living Research Utilization Sample Checklist 1 Nursing Home Transition Needs Survey Developed by Julie Alexander, Independent Living Coordinator and Advocate for IndependenceFirst 28

30. New Community Opportunities Center at ILRU – Independent Living Research Utilization Checklist 1: Sample Questions – Housing Services Have you obtained a housing list from an Independent Living Coordinator? Have you placed your name on a waiting list for a housing complex in which you would like to reside? Do you need accessible housing? Do you have funds to pay for housing? Are you being evicted from your current living situation? If so, when? What is your target date for moving? What is the date of your lease? Have you reviewed your lease? What is the date housing was secured? What date was the security deposit paid and rent paid? What date is the move scheduled for? What is the date you pick up your keys? If needed, are duplicate key(s) and/or key cards made and obtained? 29

31. New Community Opportunities Center at ILRU – Independent Living Research Utilization Sample Checklist 2 Transition Planning Work Sheets Adapted from “How to Free Our People: Real Life Solutions”, A National Conference Participant’s Manual, May 21-23, 2003 30

32. New Community Opportunities Center at ILRU – Independent Living Research Utilization Checklist 2: Sample Planning Worksheet - Health Priorities and support needs medical supplies adaptive equipment Medicaid card preventative health care pain management exercise evaluations (O.T., hearing, etc.) pharmacy community doctor therapy dentist specialists other 31

33. New Community Opportunities Center at ILRU – Independent Living Research Utilization Sample Checklist 3 Planning Tools for Assisting Individuals to Transition from Nursing Homes to Community Living (Timelines) Developed by Michigan Association of Centers for Independent Living, 1998-1999 32

34. New Community Opportunities Center at ILRU – Independent Living Research Utilization Checklist 3: Transition Planning Timelines – Personal Finance Two to Three Months Prior to the Move 1.Get SSA report to determine income post discharge. 2.Assess other income. 3.Identify personal debts. 4.Develop personal budget. One Month Prior to the Move 1.Resolve personal debts. 2.Determine money that will be required for the move and seek community resources. One Week Prior to the Move 1.Notify SSA, MA, MC, FIA of address change. 2.Review budget. 3.Set up bank account near community home. 33

35. New Community Opportunities Center at ILRU – Independent Living Research Utilization Checklist 3, cont’d. One to Two Days Prior to the Move 1.Set up automatic deposit for SSI/SSDI checks. (1-800-772-1213). Day of the Move 1.If possible, have some cash available for unforeseen expenses. First Week after the Move 1.Review & adjust budget. First Month after the Move 1.Assist consumer in paying first month’s bills. 2.Review & adjust budget as needed (e.g. monthly for 3-6 months). 34

36. New Community Opportunities Center at ILRU – Independent Living Research Utilization Develop Your Own Tools and Models These materials are meant to be used as guides and can help reassure you that you are covering all your bases. There are different models out there, but we all accomplish the same thing and… FREE OUR PEOPLE! Feel free to develop your own tools and personalized approach or model. 35

37. New Community Opportunities Center at ILRU – Independent Living Research Utilization Celebration(s) One especially thoughtful way to support the individual who has moved to the community is to remember their birthday, holidays and especially the first anniversary of the day they moved out. A card, a telephone call and/or a first year anniversary party can make a big difference. 36

38. New Community Opportunities Center at ILRU – Independent Living Research Utilization Questions and Answers 37 This is the final Question/Answer session. Feel free to ask questions about any topic covered during the four-session Webinar series.

39. New Community Opportunities Center at ILRU – Independent Living Research Utilization Contact Information One last time… Bruce E. Darling President/CEO Center for Disability Rights, Rochester NY BDarling@CDRNYS.org 585-546-7510 38

40. New Community Opportunities Center at ILRU – Independent Living Research Utilization 39 Wrap Up and Evaluation Please complete the evaluation of this program by clicking here: https://vovici.com/wsb.dll/s/12291g4c0ff

41. New Community Opportunities Center at ILRU – Independent Living Research Utilization New Community Opportunities Attribution 40 This webinar is presented by the New Community Opportunities Center, a national training and technical assistance project of ILRU, Independent Living Research Utilization. This webinar was organized and facilitated by the National Council on Independent Living (NCIL). Support for development of this presentation was provided by the U.S. Department of Education, Rehabilitation Services Administration under grant number H400B100003. No official endorsement of the Department of Education should be inferred. Permission is granted for duplication of any portion of this slide presentation, providing that the following credit is given to the project: Developed as part of the New Community Opportunities Center at ILRU.