Long-Term Care

This case study describes the leveraging and coordinating of multiple funding resources to provide increased access to home modifications and assistive technology in response to an assessment of individualized need. The Nebraska Assistive Technology Project serves as a single provider to conduct program eligibility for all funders, and provide assessment, determine need, and develop a service plan for consumers.

A publication that may be useful for legal guardians as they consider or prepare for a a transition planning process for the person they represent. This book guides the process in determining if a person can live in the community, and what that community living environment would need to look like. The purpose of this guidebook is to provide information about the variety of community residential options available to adults with developmental disabilities who relocate from State Centers.

Subtitled \"An Information Booklet for Guardians of Individuals who are Protectively Placed and Living at a State Center\", this booklet provides guardians with an updated view of changes currently taking place within the state of Wisconsin. It also encourage guardians to take a more active role in the planning and review processes that determine the appropriate residential setting for the persons they represent and encourages guardians to contact the Guardian Mentor program with questions.

This is a planning document developed by the Ozaukee County Aging Services Department that helps individuals gather thoughts and discuss them with their family by asking, What Do You Want? This document, subtitled “Your Personal Guide for Planning a Happy Healthy & Independent Long Life” helps individuals take an inventory of the values and preferences. The guide recommends recording what you want and reviewing the list periodically with those closest so they can carry out the plans.

The Turner Geriatric Clinic Social Work Department established a community-hospital liaison as part of the Michigan Nursing Facility Transition grant. This report discusses the goals of the project, its development and implementation, challenges and successes, and the end results.

This series of worksheets provides examples of what the Michigan Nursing Facility Transition grant used in planning the transition from the nursing facility to the community. Review the worksheets for Daily Living, Employment Planning, Financial Planning, Health Planning, Housing Planning, Planning Template, Self-Determination, Social and Transportation Planning.

Michigan developed a six-part training on transition and diversion. Module 6, the final module in this series, is an overview of organizational impact and collaboration in nursing facility transition. This section provides information on how developing nursing facility transition capacity may impact an organization and team. It also provides information on “bringing all the resources” together. The Appendix is also included.

Michigan developed a six-part training on transition and diversion. Module 5 guides service providers through the transition periods and its follow-up. Handouts include transition planning guidelines and timelines, nursing facility transition services, and expenditure reports.

Michigan developed a six-part training on transition and diversion. Module 3 discusses outreach activities in nursing facility transition and diversion. It reviews different methods of outreach and how they can be developed to be effective forms of marketing. In addition, information for outreach contacts and resources is provided.

A goal of the Maryland Real Choice grant was to “provide information and assistance to consumer in acute care hospitals to aid decision-making and assist with transitions back to the community.” In 2003, a hospital discharge initiative was used to pay for nurses to work with patients being discharged from acute-care hospital stays. This paper reviews and answers whether there has been any change in discharge patterns from pilot sites to nursing homes relative to the rest of the state.