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Nursing Facility Transition and Diversion

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

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Nursing Facility Transition and Diversion

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  1. Nursing Facility Transition and Diversion Module 5: Transition, Follow-up, Tools and Resources

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

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

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

  9. Transition and Follow-up • Follow-up • The next day • The next month • The next year

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

  11. 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

  12. Tools and Resources for Transition • Nursing Facility Transition Services-HO#5 • Civil Monetary Penalty Funded Nursing Facility Transition Codes-HO#6

  13. 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

  14. 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

  15. 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

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