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Pre-Meeting: Interactive Learning Carousel
Station 1
Why are you here today?
Station 1: Why are you here?
I am here because I care about what I do and how I do it in transitioning individuals into community living.
Station 1: Why are you here?
To learn about resources for transitions
Station 1: Why are you here?
To learn more resources that are available for community transitions
Station 1: Why are you here today?
Planning to implement a lot with COPD (high risks + readmission). New ideas?
Station 1: Why are you here today?
To learn and reflect-what do other people do that works well and I could do also?
To gain knowledge about transition resources avail
Station 1: Why are you here today?
To learn + exchange ideas to share what tools we have + hopefully learn more to become better with transitioning people
Station 1: Why are you here today?
Exchange ideas
Station 1: Why are you here today?
Develop and/or learn innovative strategies. How are others doing it
Station 1: Why are you here today?
Learn how to better coordinate successful transitions from SNF’s
Station 1: Why are you here today?
To network
Station 1: Why are you here today?
To increase my knowledge of resources for transitioning from program to another
Station 1: Why are you here today?
Network and learn more about community
Station 1: Why are you here today?
Hear more about resources program in NC
Station 1: Why are you here today?
To learn as much as possible to better asst my patients
Station 1: Why are you here today?
To better learn a cohesive path to ensure smoother transitions for care & to learn!
Station 1: Why are you here today?
To gain more insight on the transition process, also possibly network with other transition team leaders, to also take back some info to my facility to better meet the needs of population I serve (complex patients)
Station 1: Why are you here today?
To learn how to overcome obstacles in transition process
Station 1: Why are you here today?
1. Interested in topics, i.e. Job/work 2. Increase referrals... for MFP
Station 1: Why are you here today?
To learn more about transition planning, things I don’t already know, and learn from my peers
Station 1: Why are you here today?
To become more effective as a transition coordinator
Station 1: Why are you here today?
To increase my knowledge of comm resources
Station 1: Why are you here today?
To hopefully learn ways/techniques to assist me when pts transition from one healthcare setting to the next
Station 1: Why are you here today?
To learn more about resources available in the community for my residents who are discharging
Station 1: Why are you here today?
Station 1: Why are you here?
To learn & share strategies that will allow for smooth transitions to home & reduce readmissions
Station 1: Why are you here?
Additional info on transition
How to better assess which patients are likely to successfully transition into the community
Station 1: Why are you here today?
To learn new skills, to present, and meet others that have a shared interest in helping individuals with I/DD and Autism
Station 1: Why are you here today?
To gain the skills necessary to lead individuals & other professionals into successful transitions
Station 1: Why are you here today?
Learn and grow
Station 1: Why are you here today?
To learn how D.C. Senior Services can play a role in
transitions
Station 1: Why are you here today?
To learn resources to better assist community transitions
Station 1: Why are you here today?
Station 1: Why are you here?
Learn, Share, Act
Station 1: Why are you here?
To gain better knowledge & resources for transitions
To learn as much about the MFP process, to be better at my job
Station 1: Why are you here today?
To learn more info about the transition process
Station 1: Why are you here today?
Interested in being part of conversation to address needs of folk transition
Station 1: Why are you here today?
Learn about more resources for people who are transitioning, learn how to engage family & guardians
Station 1: Why are you here today?
Try to update peers of incredible fast pace of hospital difficulty of stress
Station 1: Why are you here today?
To hopefully bring back some good community resources that will help myself and my co-workers in our discharge planning
Station 1: Why are you here today?
Learn how to break down barriers w/ transitions process
Station 1: Why are you here today?
To grow professionally, to learn, to network
Station 1: Why are you here today?
Learn others’ golden nuggets about best person-centered practices and applied to quality transitions into real community life
Station 1: Why are you here today?
To put things in perspective
Station 1: Why are you here today?
The potential to affect change
Station 1: Why are you here today?
To be able to enhance my knowledge, improve our transitions care program, to expand in all care settings
Station 1: Why are you here today?
Station 2
What facilitates (supports) transition efforts?
Station 2: What facilitates (supports) transition efforts?
Communities
Station 2: What facilitates (supports) transition efforts?
Coordination
Station 2: What facilitates (supports) transition efforts?
Supporting the person’s goals
Station 2: What facilitates (supports) transition efforts?
Getting input from the person who is transitioning
Station 2: What facilitates (supports) transition efforts?
Resources & referrals
Station 2: What facilitates (supports) transition efforts?
What team members can do & what their agency can provide
Station 2: What facilitates (supports) transition efforts?
Transition coordinator/agency developing strong collaborative partnership
Station 2: What facilitates (supports) transition efforts?
Effective communication b/w community base providers & hospitals
Station 2: What facilitates (supports) transition efforts?
Realistic expectations
Station 2: What facilitates (supports) transition efforts?
Knowledge of sustainable supports
Station 2: What facilitates (supports) transition efforts?
Collaborative work among agencies
Station 2: What facilitates (supports) transition efforts?
Community effort-everyone on the same page working toward the same goal
Station 2: What facilitates (supports) transition efforts?
Staying person-centered
Station 2: What facilitates (supports) transition efforts?
Good action plan & someone they can call on
Station 2: What facilitates (supports) transition efforts?
Open-minded, not imposing your belief values
Station 2: What facilitates (supports) transition efforts?
Natural supports & invested team members
Station 2: What facilitates (supports) transition efforts?
Supportive family
Station 2: What facilitates (supports) transition efforts?
Primary care
Station 2: What facilitates (supports) transition efforts?
Communication
Station 2: What facilitates (supports) transition efforts?
Administrations that understand the process
Station 2: What facilitates (supports) transition efforts?
A team of people who we can rely on! As a transition coordinator, I know some things- but need a good tam/network to ask questions
Station 2: What facilitates (supports) transition efforts?
Team work among all players
Station 2: What facilitates (supports) transition efforts?
Relationship and rapport with individual
Station 2: What facilitates (supports) transition efforts?
Good communication between programs
Station 2: What facilitates (supports) transition efforts?
Person being open to next level of care
Station 2: What facilitates (supports) transition efforts?
Other professionals understanding the program (MFP, PACE)
Station 2: What facilitates (supports) transition efforts?
The needs of the person needing transition care
Station 2: What facilitates (supports) transition efforts?
A positive attitude from all team members so that the person can be successful
Station 2: What facilitates (supports) transition efforts?
Teamwork and open communication
Station 2: What facilitates (supports) transition efforts?
The attitudes of the care worker & the individual transitioning &
knowledge of care worker to resources available
Station 2: What facilitates (supports) transition efforts?
Addressing barriers
Station 2: What facilitates (supports) transition efforts?
Use of evidenced-based practices across the continuum
Station 2: What facilitates (supports) transition efforts?
Referrals & coordinating with resources for a successful transition
Station 2: What facilitates (supports) transition efforts?
Good communication, available resources, patient/family buy-in/support
Station 2: What facilitates (supports) transition efforts?
Involvement of durable medical providers, such as respiratory post D/C
Station 2: What facilitates (supports) transition efforts?
Strong support system “family, church, friends, neighbors”
Station 2: What facilitates (supports) transition efforts?
Natural support, good plan developed with individual, monitoring and .... addressing barriers
Station 2: What facilitates (supports) transition efforts?
Provider agencies, developmental centers & MCOs
Station 2: What facilitates (supports) transition efforts?
Trust & relation support
Station 2: What facilitates (supports) transition efforts?
Collaboration among supports
Station 2: What facilitates (supports) transition efforts?
People who are willing to take risks!
Station 2: What facilitates (supports) transition efforts?
Being a knowledgeable guide
Station 2: What facilitates (supports) transition efforts?
Positive attitude, wanting to learn, avail resources, be realistic and honest
Station 2: What facilitates (supports) transition efforts?
Consideration of the whole person and identifying best and worst scenarios and planning for the most support possible
Station 2: What facilitates (supports) transition efforts?
Good action plan & someone they can call on
Station 3
What are the barriers (hinders) to transition efforts?
Station 3: What are the barriers (hinders) to transition efforts?
Lack of staff with base community resources
Station 3: What are the barriers (hinders) to transition efforts?
Issues with school systems not being tolerant
Station 3: What are the barriers (hinders) to transition efforts?
No placements available for adults/children that can meet needs. Providers saying they have availability, capability, experience but don’t
Station 3: What are the barriers (hinders) to transition efforts?
Lack of knowledge of what each level of care can provide among providers
Station 3: What are the barriers (hinders) to transition efforts?
Lack of communication or warm hand off to community-based providers, hospitalization
Station 3: What are the barriers (hinders) to transition efforts?
Occasional lack of transparency
Station 3: What are the barriers (hinders) to transition efforts?
Political will to remove all the barriers
Station 3: What are the barriers (hinders) to transition efforts?
Lack of knowledge on possible purchasing a home
Station 3: What are the barriers (hinders) to transition efforts?
Need for additional technology rest assured
Station 3: What are the barriers (hinders) to transition efforts?
Money within communities to provide resources & FTEs
Station 3: What are the barriers (hinders) to transition efforts?
Not identifying needs prior to discharge, i.e. equipment, financial capability to pay for medicines etc.
Station 3: What are the barriers (hinders) to transition efforts?
No funds available within the time needed for services trying to access
Station 3: What are the barriers (hinders) to transition efforts?
Lack of resources
Station 3: What are the barriers (hinders) to transition efforts?
Willingness of the person to apply for resources
Station 3: What are the barriers (hinders) to transition efforts?
Lack of resources, “transportation”, housing
Station 3: What are the barriers (hinders) to transition efforts?
Medicaid deductible
Station 3: What are the barriers (hinders) to transition efforts?
Categories of support: there are always people who fall thru the cracks, don’t qualify-we need to be creative about making sure they have needs met!
Station 3: What are the barriers (hinders) to transition efforts?
Limited ICF (intermediate care facility)
vacancies
Station 3: What are the barriers (hinders) to transition efforts?
No insurance, self pay
Station 3: What are the barriers (hinders) to transition efforts?
No primary care giver but trying to figure out how to access their rights
Station 3: What are the barriers (hinders) to transition efforts?
Lack of family/community support
Station 3: What are the barriers (hinders) to transition efforts?
Low income
Station 3: What are the barriers (hinders) to transition efforts?
Limited resources
Station 3: What are the barriers (hinders) to transition efforts?
Housing/criminal background before disability
Station 3: What are the barriers (hinders) to transition efforts?
Home repairs
Station 3: What are the barriers (hinders) to transition efforts?
Knowledge of resources, i.e. Home mod, housing
Station 3: What are the barriers (hinders) to transition efforts?
Organizational policies & procedures
Station 3: What are the barriers (hinders) to transition efforts?
Organizational policies & procedures
Station 3: What are the barriers (hinders) to transition efforts?
Transitioning pts from home to SNF and haven’t seen MD in
months/years
Station 3: What are the barriers (hinders) to transition efforts?
Rural areas with limited resources especially
transportation
Station 3: What are the barriers (hinders) to transition efforts?
Rural areas (lack of resources)
Station 3: What are the barriers (hinders) to transition efforts?
Communications, lack of technology in home
Station 3: What are the barriers (hinders) to transition efforts?
Wait time-transition process takes too long and they get frustrated
Station 3: What are the barriers (hinders) to transition efforts?
Lack of housing/support systems
Station 3: What are the barriers (hinders) to transition efforts?
Unrealistic expectation of person, lack of acceptable understanding of medical needs
Station 3: What are the barriers (hinders) to transition efforts?
Lack of finances, community support, and options
Station 3: What are the barriers (hinders) to transition efforts?
Lack of community, family support
Station 3: What are the barriers (hinders) to transition efforts?
Hospital not aware of community partners (if person doesn’t tell
staff)
Station 3: What are the barriers (hinders) to transition efforts?
Patient + medical team not having same goals
Station 3: What are the barriers (hinders) to transition efforts?
Lack willing or capable caregivers
Station 3: What are the barriers (hinders) to transition efforts?
Lack of transportation
Station 3: What are the barriers (hinders) to transition efforts?
On-going criminal activities
Station 3: What are the barriers (hinders) to transition efforts?
Expectation from everyone involved
Station 3: What are the barriers (hinders) to transition efforts?
Not enough resources in my area, medics/Medicaid restrictions guidelines
Station 3: What are the barriers (hinders) to transition efforts?
Funding, lack of appropriate services, lack of insight, and motivation
Station 3: What are the barriers (hinders) to transition efforts?
Time frame for application approve assessment
Station 3: What are the barriers (hinders) to transition efforts?
Affordable/accessible housing, community-based personal assistant services, policy that limits individual choice
Station 3: What are the barriers (hinders) to transition efforts?
ACTT drift of mission over the years trying to partner, equip, encourage staff to join our “mission”
Station 4
Emerging principles
Station 4: Emerging principles
What resonates with you the most? What, if anything, is missing?
Station 4: Emerging principles
Work yourself out of a job
Station 4: Emerging principles
Be creative-outside box
Station 4: Emerging principles
Flexible
Station 4: Emerging principles
Crisis planning
Station 4: Emerging principles
If nursing home patient came from home that was not
safe/cannot go back
Station 4: Emerging principles
Optimistically honest
Station 4: Emerging principles
Resonates most, being optimistically honest-if people, family know, it’s better for them to plan
Station 4: Emerging principles
Assessment-building relationship
Station 4: Emerging principles
Optimistic honesty + education
Station 4: Emerging principles
Not chaotic or sluggish, keeping momentum going hard
Station 4: Emerging principles
Center is person & family
Station 4: Emerging principles
Participant in the middle (harder than it looks)
Station 4: Emerging principles
Individual is guiding the goals
Station 4: Emerging principles
Empowering person to take responsibility
Station 4: Emerging principles
Making LTC facilities know about transitions opportunities-for public too
Station 4: Emerging principles
Community-based services, housing, transportation, individual choice
Station 4: Emerging principles
Holistic perspective
Station 4: Emerging principles
Put everything in place
Station 4: Emerging principles
Warm hand offs
Station 4: Emerging principles
Collaborating with others
Station 4: Emerging principles
Relationship building with participant—family
Station 4: Emerging principles
Communication & other systems SS/DSS/AEC, etc.
Station 4: Emerging principles
Need to know continuity of resource knowledge & communication
Station 4: Emerging principles
Don’t have to be an expert in everything
Station 4: Emerging principles
Teamwork
Station 4: Emerging principles
Communication, funds, step out of the box, ...
Station 4: Emerging principles
There should be conversations with guardians/people about transition prior to making application. Sometimes when I come to initial meetings-the guardian/person has no idea why I am there and I have to awkwardly explain. There should be several initial conversations with the team prior to beginning the MFP process.
Station 4: Emerging principles
Tracking outcomes to provide evidence-based practices