Transcript NCO presents

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 – Independent Living Research Utilization
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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 – Independent Living Research Utilization
1
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.
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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Community Alternatives Project Team
ILRU’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
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DONE! No so fast…
The person has transitioned into the community.
We’re done. Right?
No.
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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 posttraumatic 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? Fulltime? 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?
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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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?
New Community Opportunities Center at ILRU – Independent Living Research Utilization
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Questions and Answers
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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
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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
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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 Move
1. 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 Move
1. Resolve personal debts.
2. Determine money that will be required for the move and seek community
resources.
One Week Prior to the Move
1. 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 Move
1. Set up automatic deposit for SSI/SSDI checks. (1-800-772-1213).
Day of the Move
1. If possible, have some cash available for unforeseen expenses.
First Week after the Move
1. Review & adjust budget.
First Month after the Move
1. 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
This is the final Question/Answer session.
Feel free to ask questions about any topic
covered during the four-session Webinar
series.
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Contact Information
One last time…
Bruce E. Darling
President/CEO
Center 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
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New Community Opportunities
Attribution
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.
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