Grantee produced

Washington’s automated, comprehensive, person centered assessment and planning tool measures the personal care needs of anyone receiving services at home or in a residential setting and develops a care plan. The tool contains 60 different screens, some relate to risk. Participant selects a service setting and then the program computes eligibility, need and a service plan that crosses settings. The package contains: CARES Training Manual, CARES Assessment, Eligibility & Rates for LTC Services.

Developed by Oregon’s Office of Home & Community these tools include consideration of 43 areas of risk and illustrates the state’s risk tracking documentation in Q&A format. They also provide instruction to staff with loops back to participant preference and guidance to protocols to address identified risks. Forms included: ISP Addendum, Financial & Individual Support Plan, Personal Focus Worksheet, Risk Training, Protocol for Aspiration, Constipation, Dehydration, Seizure and Signature Sheet.

Developed by the New York Department of Health this tool is used for participants with traumatic brain injury. The tool identifies risk factors and the services needed to mitigate them, and assigns specific persons who will be responsible for providing the necessary service and oversight. Addressed in the plan: money management, medication management, kitchen safety, back-up staffing for unscheduled staff absences. Plans are revised at least every six months and must be signed.

This quality tool product was developed by the state of Arizona, Department of Economic Security. The Prevention and Risk Assessment form identifies risk in a variety of dimensions, including home, work, and the community. The tool identifies risk prevention and mitigation strategies, as well as needed supports and the individuals who can/will provide these supports.

Discussion at this meeting was lively and productive, and the opportunity to meet people from other parts of the state and other municipalities proved fruitful. Following the suggestion of participants in the October Forum, the agenda included presentations of what the three Model Communities have done and how it is working, and sharing of successes, ideas and resources among other participating towns.

Gainful employment is entirely possible for people with disabilities and yet it remains outside the grasp for many who remain unemployed or grossly underemployed. Success in employment is caught in a vicious circle with the insufficiency of employment supports, health care coverage, education and training, and income potential. Further aggravating that cycle are barriers in transportation, child care, accessible and affordable housing.

Discussion at this meeting was lively and productive, and the opportunity to meet people from other parts of the state and other municipalities proved fruitful. The idea of adapting the “lessons learned” in the model communities and hosting regional meetings was introduced; a shared enthusiasm for the idea gave rise to a series of Regional Forums. This forum, held in Groton, CT was the second in the series, held on December 3, 2004.

This guide was created as a resource to help you learn more about communication boards and how/when to use them. The boards in this kit were designed for a specific communication interaction, an intake interview to consider transition of an individual out of a nursing home. This handout provides a brief summary of the communication boards provided and some background information for you as you use the boards.

This handbook, drafted by Jane Schiele and edited and revised by Laura Hershey (HCPF Systems Change Section), is designed to help other advocates or agencies to inform many more individuals about their right to live in the community, and to assist those who desire a transition back to their community. The report defines transition and offers the nuts and bolts of the program and lastly overs tips for moving day and beyond.

This survey was developed by the Colorado Facility Transition grant to evaluate the transition process of individuals across Colorado. Results from this survey were used to develop and implement changes in the transition process to better serve the population. The form is for people who have moved out of a nursing home in Colorado within the last two years. How you fill in this form is important because the answers help other people who will move from a nursing home soon.