1 / 21

Nursing Facility Transition and Diversion

Learn essential steps for successful transition from nursing facility with key issues, assessment guidance, and community resource links.

tmcgeehan
Télécharger la présentation

Nursing Facility Transition and Diversion

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Nursing Facility Transition and Diversion Module 4: Nuts and Bolts of Transition

  2. Overview • Key Issues for Successful Transition • Initial Meeting and Assessment • Person-Centered Plan • Housing • Transportation • Other Issues

  3. Key Issues for Successful Transition 1. Motivation 2. Length of Nursing Facility Stay 3. Natural Supports

  4. Key Issues for Successful Transition 4. Eligibility for Support • Michigan Protection and Advocacy Services (MPAS) • (800) 288-5923 5. Access to Housing

  5. Key Issues for Successful Transition • Positive reputation with agencies • History of utility bills paid on time • Strong credit

  6. Key Issues for Successful Transition • Family support and unity 10. No substance abuse history/behavior or strong record of recovery • Mental Health support

  7. Key Issues for Successful Transition • Guardianship • Michigan Protection and Advocacy Services (MPAS) • (800) 288-5923

  8. 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

  9. 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

  10. 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

  11. Initial Meeting and Assessment • 12 Issues related to successful transition • Veteran status

  12. 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

  13. Person-Centered Planning • Dreams • Nightmares, concerns, or fears • Independence • Financial • Safety • Relationships • Care Needs

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

  15. Financial • Social Security • Social Security Administration (800) 772-1213 • Food Stamps

  16. Housing • If consumer already has home • Make a home visit • Accessibility and safety issues • Household needs • Durable Medical Equipment (DME) needs

  17. Housing • Subsidized Housing • Supported Housing • If housing is needed: • Call apartment complexes • On site visits • Rental information • Utility information • Criminal background checks

  18. Transportation • Bus Availability • Paratransit application • From nursing facility to own home or apartment

  19. Resources • Substance Abuse • A listing of substance abuse regional coordinating agencies: • http://www.michigan.gov/documents/CA_Contact_List_123511_7.pdf • Mental Health • A listing of all of the Community Mental Health Agencies: http://www.macmhb.org/directory/directory05-06.pdf • Mediation • A listing of Centers for Dispute Resolution in Michigan: • http://courts.michigan.gov/scao/resources/other/cdrpcenters.pdf • Financial Education • For information on the local sites for Building Your Financial Future which provides financial education for people with disabilities go to: • http://www.copower.org/AT/BYFFlocal.htm

  20. Resources • Guardianship • For more information about Michigan Protection and Advocacy Services go to their website: www.mpas.org • Housing Information • Directory of Subsidized Housing: http://www.mshda.info/housing/ • Corporation for Supportive Housing: 810-229-7712 • Social Security Administration website: www.ssa.gov • Food Stamps • A Listing of local Department of Human Services Offices can be found by going to www.michigan.gov/dhs and clicking on County Offices on the toolbar on the left side of the page.

  21. Resources • Transportation • A listing of all public transit providers in Michigan can be found at the MDOT website: • http://www.michigan.gov/mdot/0,1607,7-151-9625_21607-31837--,00.html • You can get to this link by going to www.michigan.gov/mdot 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

More Related