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Nursing Facility Transition and Diversion

This module on nursing facility transitions focuses on the comprehensive process involved in transitioning individuals from nursing facilities to independent living. It includes essential steps to initiate the transition, a timeline for preparations, and critical follow-up actions post-move. Key elements discussed include securing housing, organizing support services, and ensuring access to necessary medical and household resources. The module offers practical tools, checklists, and examples to facilitate smooth transitions, ensuring that residents have the support they need moving forward.

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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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