Nursing Home Transition 4-Part Webinar Series Part 4: Following Up After the Move October 12, 2011

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…


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…


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.


Community Alternatives Project TeamILRU’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

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.


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


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


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


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


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


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?

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Housing, cont’d.

• If there is a roommate, is this working out?

• Are additional furnishings needed?

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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?

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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?

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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?

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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?

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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?

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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?

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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?

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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?

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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?

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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”?

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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?

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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?

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Questions and Answers


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

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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

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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

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Sample Checklist 1

Nursing Home Transition Needs Survey

Developed by Julie Alexander, Independent Living Coordinator and Advocate for IndependenceFirst

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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?

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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

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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

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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

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Checklist 3: Transition Planning Timelines – Personal Finance

Two to Three Months Prior to the Move1. 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 Move1. Resolve personal debts. 2. Determine money that will be required for the move and seek community

resources.

One Week Prior to the Move1. Notify SSA, MA, MC, FIA of address change.2. Review budget. 3. Set up bank account near community home.

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Checklist 3, cont’d.

One to Two Days Prior to the Move1. Set up automatic deposit for SSI/SSDI checks. (1-800-772-1213).

Day of the Move1. If possible, have some cash available for unforeseen expenses.

First Week after the Move1. Review & adjust budget.

First Month after the Move1. Assist consumer in paying first month’s bills. 2. Review & adjust budget as needed (e.g. monthly for 3-6 months).

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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.

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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.

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Questions and Answers

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This is the final Question/Answer session.

Feel free to ask questions about any topic covered during the four-session Webinar series.


Contact Information

One last time…

Bruce E. DarlingPresident/CEOCenter for Disability Rights, Rochester NY [email protected] 585-546-7510

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Wrap Up and Evaluation

• Please complete the evaluation of this program by clicking here:

https://vovici.com/wsb.dll/s/12291g4c0ff

https://vovici.com/wsb.dll/s/12291g4c0ff


New Community Opportunities Attribution

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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.

Documents

Nursing Home Transition 4-Part Webinar Series Part 4: Following Up After the Move October 12, 2011