Roads to Community Living (RCL) Person Centered Transition ...



INDIVIDUAL’S NAME FORMTEXT ?????ADSA ID NUMBER FORMTEXT ?????PROPOSED MOVE DATE FORMTEXT ?????INDIVIDUAL’S STATED TRANSITION GOAL FORMTEXT ?????INDIVIDUAL’S STATED SUPPORTS NEEDED TO ACHIEVE GOAL FORMTEXT ?????DEVELOPMENT DISABILITIES ADMIISTRATION (DDA)Transitional Care Planning TrackingPurpose: This is a required document intended to be used as a facilitation guide and tracker for DDA staff coordinating a move from one setting to another. Case Managers facilitation transitional care coordination meetings will use this document with each meeting to track progress and highlight individual needs and readiness to transition to their identified setting. A copy will be provided to the individual and their representative to update them on transition progress as well as to transition progress as well as to transition team members as appropriate. Transition Preparation: Individual requests to move to a new setting.Transition preparation consists of the tasks that are needed to identify the FORMTEXT ?????’s goals and support needs, identify FORMTEXT ?????’s preferred setting to live, and review eligibility for applicable programs. FORMTEXT ?????’s primary case manager works to begin transition planning. In some cases the individual will transfer to a transition or RCL caseload. In these cases, the primary case manager will transfer the case after mutual acceptance has occurred between an individual and a provider after a warm handoff.ACTIVITYWHODUE DATENOTES AND STATUS UPDATESDONEDATEReview existing available supports with FORMTEXT ????? / family / guardian FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? / family / guardian tours and interviews community providers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? assist to complete or update MyPage and incorporate into client profile FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Discuss living options and identify preferred living arrangement and identify appropriate community living model that matches FORMTEXT ????? ‘s description FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Determine financial eligibility for applicable programs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Review CARE and ensure it is current and accurate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Assemble and send referral packet form and provider level to residential referral inbox and follow referral process per policy FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Consent forms signed to share information FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Have conversation with guardian about providing needed legal documents (refer to form DSHS 10-635):Washington State ID,Current legal decision-making paperwork,Social Security Card,Insurance cards, andAny other legal documents. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Region sends referral packet with five (5) business days to identified community residential provider(s) preferred by FORMTEXT ????? / family / guardian FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Providers meet FORMTEXT ????? in current setting; gather additional information FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Location of the home has been identified FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????CRMs for FORMTEXT ????? and housemates have discussed compatibility of individuals FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Housemates met and agreed to live together FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Necessary environmental modifications identified FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????RM verified that the provider agreed to provide support to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????CRM verified FORMTEXT ????? / guardian have agreed to receive services from the provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Ensure that needed ETR requests for rate adjustments are submitted FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????LTC notified of tentative move date and eligibility confirmation has been requested FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Mutual agreement when FORMTEXT ????? has chosen a provider to meet their care needs and the provider agrees to provide care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Warm Handoff: Sending and receiving CRMS (if transitioning to a new CRM) work with FORMTEXT ????? and guardian, as well as the current and future provider to review the individual’s goals, understand their support needs and create the transition team. The case manager convenes the initial meeting to develop the transition plan. The initial meeting marks the beginning of the Active Coordinator of Transition (ACT) stage.If cross-regional move, schedule internal DDA meeting with case managers and region to FORMTEXT ?????’ needs.Sending CRM: FORMTEXT ?????Receiving CRM: FORMTEXT ?????Date: FORMTEXT ?????Meet with current and new provider and case manager(s) and ensure new residential provider has copies of all relevant documents on the DSHS 10-635 checklist. Document missing items. Identify transitional care coordinator team members (warm handoff). FORMTEXT ?????Date: FORMTEXT ?????Please describe how the individual and their guardian or representative would like to participate in the meetings and receive updates about the transition status: FORMTEXT ?????B. Active Coordinator of Transition (ACT): Team meets regularly to support transitionTransition TeamThe transitional care coordination team meets regularly to develop and implement the care plan, identify medical, dental, and referral and assessment needs, set up housing, identify and implement environmental modifications and equipment needs, confirm financial eligibility, facilitate introductions to providers, roommates and community activities.Please be sure to include FORMTEXT ????? in identifying who should be at their meeting and ensure that they provide permission for attendance. All participants in a meeting should have copies of the tracking notes to ensure they are able to monitor due dates and transition progress. TITLE / ORGANIZATIONNAMEROLECONTACT INFORMATIONIndividual FORMTEXT ?????Engage with the team on community living goals and preferences FORMTEXT ?????DDA Transition Case Manager FORMTEXT ?????Facilitate transitional care coordination meetings; coordinate assignments and deadlines; model person centered practices FORMTEXT ?????Current / Sending Provider FORMTEXT ?????Provide expertise regarding individual’s care needs FORMTEXT ?????Medical Provider FORMTEXT ?????Discuss medical supports needed, including post move medications and referrals to appropriate PCP or specialists if needed FORMTEXT ?????Behavioral Health Provider FORMTEXT ?????Discuss behavioral supports needed, including post move psych medications and FA/PBSP coordination FORMTEXT ?????DDA HQ Clinical Staff FORMTEXT ?????If identified high medical or behavioral acuity, or if otherwise needed for consultation FORMTEXT ?????Receiving Provider FORMTEXT ?????The agency or responsible provider of services in the setting where the individual will move FORMTEXT ?????Guardian or Representative FORMTEXT ?????Support the individual with decision making regarding implementation of their goals and needed supports and services FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEDICAL, DENTAL BEHAVIORAL PERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATEMCO care coordination needs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Primary care confirmed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Specialists needed are in place FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Dentist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Therapy needs:PT / OT / STDietary FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Psychiatric needs, including prescriber, if needed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Community behavioral health provider identified and follow up FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????New pharmacy setup FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Other health needs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????HOUSINGPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATEEnvironmental modifications needed / set up FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Rental application and lease completed / in place FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Furnishings and décor FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Resource management FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Meet staff, roommates, and visit home FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????SERVICES SET UPPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATEConfirm or initiate waiver or RCL enrollment FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Nurse delegator identifiedMedication assistance needs are identifiedDate of move delegation scheduled FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Adaptive / AT equipment in place for sensory, communication, and ADL needs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Employment / school / community inclusion FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Transportation needsWill individual need specialized transportation to access their community? Who will transport them to upcoming appointments? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????FINANCIAL AND LEGALPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATEVerify SSI, SSDI, and other unearned income in place FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Establish payee if needed, review financial supports for plan FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Apply for food programs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Are they on the correct funding program (RCL / Waiver)? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Reconcile finances in current setting FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Guardianship paperwork in place, if applicable FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Bank account is setup in new location FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????PLANS IN PLACEPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATEFA/PBSP FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Cross Systems Crisis Plan (CSCP) or safety plan, if needed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Care plan, IISP, or negotiated services plan per program policy FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????ETR / ETPs are in place FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????STAFF TRAININGPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATENurse delegation in place for all staff FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Staff trained on care plans and individual support needs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Prior to move in dateCurrent provider / new provider consultation FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????All needed documents in client provider file FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????All previous tasks have been reviewed and completed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????DAY OF MOVEPERSON RESPONSIBLEDUE DATENOTES AND STATUS UPDATESDONEDATETransportation to new home FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Items to be movedProperty list confirmed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Provider receives medications and MAR FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Finances are transferred FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Arrangements for meals enroute FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Confirm the move on theDSHS 15-345 LTC form FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????C. Post Move and StabilizationThe case manager visits at regular intervals and meets with the individual to ensure they are adjusting, ensure that staff are trained and implementing planned strategies to support the individual, and that all plans are in place and being implemented. The PQI staff works with the case manager to have conversations about identified concerns from the Mover’s Survey so that the case manager can follow-up and address any unmet needs.Two – three business days post move – individual is getting settled.ACTIVITYNOTESRESOLUTION NEEDEDDUE DATEIndividual is comfortable with staff FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Provider is comfortable with supports in place FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Issues with behaviors, nutrition, medications, etc. FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????FA / PBSP in place and staff trained FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual is satisfied with sleep and daily routine FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Nurse delegation is in place and medications are being used FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Two weeks post move – staff are able to address client’s needs.Individual is comfortable with staff FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Provider understands individual’s support needs and comfort with interventions FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Issues with behaviors, nutrition, medications, etc. FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual is satisfied with sleep and daily routine FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual is planning community activities of interest FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual shares general feedback about their experience so far FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????30 days post move – plans are all in place.Provider has finalized IISP, NCP, or other relevant care plans FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Home is decorated and personalized per the individual’s preference FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????All staff have completed needed or required training to meet individual’s needs FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual is participating in community activities of interest FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Individual has unmet needs or areas of concern to be addressed FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Quarterly check ins (3 months / 6 months / 9 months / 11 months)ACTIVITYRESOLUTION NEEDEDNOTESDUE DATE FORMTEXT ????? is engaged in community activities FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ?????Supports in place are meeting the support needs for FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ????? FORMTEXT ????? is participating in the cultural and spiritual activities of their choice FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ?????All staff are familiar with FORMTEXT ????? and their needs FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ?????IISP, NCP, or other program required care plan is effectively meeting the individual’s needsVerify 60 and 90 program requirements FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ?????Updated supports, services, or needs have been identified, if applicable, and follow up is occurring FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3 months: FORMTEXT ?????6 months: FORMTEXT ?????9 months: FORMTEXT ?????11 months: FORMTEXT ????? ................
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