LEARNING OBJECTIVES

LIST KEY SERVICE NEEDS, CHALLENGES, ANTICIPATED PROBLEMS, AND

SOLUTIONS RELATED TO NURSING HOME TRANSITIONS (NHT)

DEVELOP IMPROVED COMMUNITY TRANSITION AND ONGOING INDIVIDUAL

SUPPORT PLANS FOR AND WITH PERSONS TRANSITIONING OUR OF

NURSING HOMES

APPLY LESSONS LEARNED FROM A LARGE NURSING HOME TRANSITION INTO

DEVELOPING AND IMPROVING ONGOING NURSING HOME TRANSITION

PROCESSES

WHO IS INVOLVED

Resident wants to

transition

Nursing Home Team

Community Transition

Team

Center for Independent

Living

Medical Health and Wellness Supports

Informal Supports

Independent Living

Supports

NORMA ROBERTSON-DABROWSKI

VIDEO ABOUT NURSING HOME TRANSITION

NORMA ROBERTSON-DABROWSKI

WHAT IS NEEDED

HOUSING

PERFORM A HOUSING ASSESSMENT

IDENTIFY NEIGHBORHOODS

APPLY FOR ASSISTANCE PROGRAMS

SUBMIT APPLICATIONS

OBTAIN NEW HOME NECESSITIES

PREPARE FOR MOVE-IN

FINANCES

PREPARE MOVE IN BUDGET AND

SAVINGS

REVIEW ONGOING BUDGET

IDENTIFY BANK ACCOUNT OR

MECHANISM FOR MONEY

PLAN FOR SET-UP/TRANSFER REP

PAYEE IF NEEDED

SERVICES

DEVELOP INDIVIDUAL GOALS, SUPPORT

PLAN AND NEEDS

CONNECT WITH CENTER FOR

INDEPENDENT LIVING

APPLY FOR COMMUNITY LONG TERM

SERVICES AND SUPPORT PROGRAMS

IDENTIFY COMMUNITY SERVICE

PROVIDERS AND INFORMAL SUPPORTS

REVIEW HEALTH INSURANCE OPTIONS

IDENTIFY MEDICAL PROVIDERS

GET A COMMUNITY ADVOCATE INVOLVED

WHERE TO GET THEM

CENTER FOR INDEPENDENT LIVING

CLIENT ASSISTANCE PROGRAM

OMBUDSMAN

NURSING HOME TRANSITION

PROVIDER

SUPPORTS COORDINATION ENTITY

WHY TO GET THEM

ADDED SUPPORTS TO PERSON

ONCE IN COMMUNITY

PEER TO PEER ACCESS

ENCOURAGE RESIDENT LED

APPROACH

NONCLINICAL PERSPECTIVE

WHAT THEY DO

IDENTIFY INDEPENDENT LIVING

SKILLS

HELP WITH COMMUNITY

SUPPORTS

PEER SUPPORT

NURSING HOME RIGHTS AND RESPONSIBILITIESPENNSYLVANIA LAW, 28 PA. CODE SUBPART C LONG-TERM CARE FACILITIES

• “DISCHARGE POLICY. THERE SHALL BE A CENTRALIZED COORDINATED

DISCHARGE PLAN FOR EACH RESIDENT. TO ENSURE THAT THE RESIDENT HAS

A PROGRAM OF CONTINUING CARE AFTER DISCHARGE FROM THE FACILITY.

THE DISCHARGE PLAN SHALL BE IN ACCORDANCE WITH EACH RESIDENT’S

NEEDS.”

ADDITIONAL INFORMATION

HTTP://WWW.DISABILITYRIGHTSPA.ORG/FILE/NFDISCHARGERIGHTS3.PDF

INGLIS HOUSE TO INGLIS GARDENS AT BELMONTHAD TRADITIONALLY TRANSITIONED 5-6 INDIVIDUALS ANNUALLY

ONE STAFF MEMBER PROVIDED SUPPORT FOR EACH PERSON

POTENTIAL TO DISCHARGE UP TO 30 RESIDENTS IN A 2 MONTH PERIOD

REALIZED WE HAD A LOT OF PREPARATION, COMMUNICATION TO

ACCOMPLISH IN A VERY SHORT PERIOD OF TIME

OUR GOAL WAS TO ESTABLISH “BEST PRACTICE” REGARDLESS OF THE

NUMBER OF PEOPLE TRANSITIONING

RECOGNIZING THE NEEDS OF THE INDIVIDUALS INITIALLY, 54 RESIDENTS SHOWED INTEREST IN TRANSITIONING

DEC, 2016 AT 6 AM ALL WERE UP AND READY IN LINE FOR THE FIRST COME

FIRST SERVE PRE-APPLICATION PROCESS

WIDE VARIANCE OF PREPARATION FOR MAKING THIS TRANSITION:

- JUST A THOUGHT BECAUSE THE BUILDING WAS GOING UP

- A GOAL AND DREAM TO REACH FOR INDEPENDENCE

THE BIG TRANSITION TO BELMONT GARDENS

EVERYONE WANTS A DOOR

BUILDING AND CALLING ON OUR PARTNERS

ESTABLISHED PARTNERSHIPS – LRI, PCA, INGLIS HOUSING, SCE, DURABLE

EQUIPMENT PROVIDERS, PERSONAL CARE PRODUCT COMPANIES

NEW PARTNERS TO CALL ON – SCE, PEW CHARITABLE TRUST, DURABLE

EQUIPMENT PROVIDERS, PERSONAL CARE PRODUCT COMPANIES

TEAM MEMBERS AT INGLIS

BUILDING A TRANSITION TEAM

• EXECUTIVE TEAM SUPPORT

• TEAM LEADER

• TRANSITION COORDINATOR

• NURSING LEADER & CO – WORKERS

• REHABILITATION SERVICES

• SOCIAL SERVICES

• BUSINESS OFFICE

• COMMUNITY SUPPORTS SERVICES

• ADMINISTRATIVE SUPPORT

• ADAPTED TECHNOLOGY

WHO IS THE BEST PERSON TO

ANSWER THE QUESTION?

HOW DID THE TEAM WORK & KEEP GOING

• IDENTIFY THE PROCESS ~ START TO

MOVING IN

• EACH NECESSARY ACTION PLACED

ON A TRACKING LOG

• TEAM MEMBERS ASSIGNED

RESPONSIBILITY

• TIMELY REVIEWS

• DOCUMENTED OUR ACTIONS

• REVISED THE TRACKING TOOL AS

WE EXPERIENCED THE ACTIONS

• WE KEPT TRACK OF OUR

ACCOMPLISHMENTS

OFFERINGS TO MEET INDIVIDUAL NEEDS • TRANSITION TO INDEPENDENT

LIVING CLASSES

- RESIDENTS OPPORTUNITY TO LEARN AND

PRACTICE SKILLS FOR SUCCESS

- EXTERNAL PRESENTATIONS

• REHABILITATION ASSESSMENT FOR

INDEPENDENT LIVING

- IDENTIFY LEARNING NEEDS, DURABLE

EQUIPMENT NEEDS, SELF ADMINISTRATION

OF MEDICATION

- ADAPTIVE TECHNOLOGY

• CLINICAL ASSESSMENT AND

RECOMMENDATIONS

- PRIMARY CARE PHYSICIAN

- PHYSIATRIST

- SPECIALIST – NEUROLOGIST

- MEDICATION REVIEWS

- PSYCHIATRIST AND PSYCHOLOGIST

- OUTPATIENT BEHAVIORAL HEALTH

- SUBSTANCE USE SUPPORT NEEDS

KEYS TO SUCCESS

THE PROCESS IS RESIDENT-LED

PRE-DISCHARGE MEETING

DISCHARGE MEETING

PARTNERS TOWARDS A COMMON

GOAL

PROVIDE TOOLKIT FOR SUCCESS

NH TRANSITION BINDER/CHECKLIST

FREQUENT CONTACT LIST

BACK-UP PLANS

FINANCIAL BUDGET

WRITTEN PLANS OF ACTION

PRE-DISCHARGE MEETING> ONE MONTH PRIOR TO ANTICIPATED MOVE

AGENDA FOR MEETING

ALL KEY MEMBERS OF THE INDIVIDUAL’S

TRANSITION TEAM ENGAGED

REVIEW RECOMMENDED PLAN FOR SKILLED

SERVICES, LPN SERVICES, PERSONAL ATTENDANT

SERVICES

RECOMMENDATIONS BY THE TEAM FOR SUCCESS

WRITTEN FOLLOW UP PLAN – WHO, WHAT AND WHEN

BEHAVIORAL HEALTH AND SUBSTANCE USE

SUPPORT NEEDS

WHEELCHAIR ASSESSMENT/OWNERSHIP –

SPECIALIZED MEDICAL EQUIPMENT

MEDICATION NEEDS

ANTICIPATED FINANCIAL BUDGET

SAMPLE AGENDA

DISCHARGE MEETING

7 – 10 DAYS PRIOR TO TRANSITION

AGENDA FOR MEETING

ALL KEY MEMBERS ENGAGED

REVIEW AND FINALIZE PLAN FOR

SERVICES

ONLY FINAL RECOMMENDATIONS

FINALIZE DISCHARGE DATE

SAMPLE AGENDA

INDEPENDENT LIVING CONTACTS

THERE’S SO MUCH TO DO AND SO

MANY PEOPLE THAT THINGS JUST GET

COMPLICATED.

SIMPLIFY THE PROCESS BY

DEVELOPING A FREQUENT CONTACT

LIST AND REASONS TO CONTACT

TAILORED FOR EACH PERSON.

INDEPENDENT LIVING FREQUENT

CONTACT LIST

VIRTUAL LIFE

A PILOT FOR COORDINATED CARE AND SAFE STEP DOWN FROM FACILITY CARE

STRONG COALITION OF PARTNERS WITH WEEKLY CARE COORDINATION

PARTICIPANT

PRIMARY CARE

MAGEE MEDICAL HOME

HOME HEALTH CARE AGENCY

SKILLED CARE

IMPROVED CONNECTION TO HCBS SUPPORTS COORDINATORS

COMMON CHALLENGES AND POSSIBLE SOLUTIONSSERVICES NEED TO BEGIN UPON DISCHARGE

NO INFORMAL SUPPORTS/FAMILY OPPOSITION TO TRANSITION

TRANSPORTATION SERVICES, COMMUNITY ACCESS AND ISOLATION PREVENTION

DEVELOPING BACK-UP PLANS FOR RESOURCES, SERVICES AND SUPPLIES

LEARNING TO SUCCESSFULLY LIVE INDEPENDENTLY

COMMON CHALLENGES AND POSSIBLE SOLUTIONSNEED TO GET PHOTO IDENTIFICATION AND ABILITY TO PAY FOR IT

PERSON IS NOT ELIGIBLE FOR WAIVER SERVICES

COMMUNICATION – PHONES, INTERNET AND THE TELEVISION

BALANCING INDEPENDENCE OF INDIVIDUAL AND FAMILY CONCERNS

PERSON HOSPITALIZED AT TIME OF MOVE-IN/DATE OF DISCHARGE

THANK YOU!

NORMA ROBERTSON-DABROWSKI

LIBERTY RESOURCES, INC.

112 N. 8TH ST, #600

PHILADELPHIA, PA 19107

215 634-2000

NORMAROBERTSON

@LIBERTYRESOURCES.ORG

JANET TURNER

INGLIS FOUNDATION

2600 BELMONT AVENUE

PHILADELPHIA, PA 19131

215 878-5600

JANET.TURNER@INGLIS.ORG

JULIET.MARSALA@INGLIS.ORG

JULIET MARSALA