Nursing Home Transition

The Disability Achievement Center assists residents residing in nursing homes in Pinellas and Pasco Counties with an opportunity to be assessed for independent living through the Aged and Disabled Adult Medicaid Waiver Program. The Waiver provides intermittent care and supervision in a home and community based environment as an option to nursing home placement. The population targeted are those persons residing in nursing homes who have a community residence and an informal “non-paid” support network (usually family and friends) who are able and commit to provided some care and supervision to the person transitioning from nursing home to community living. The Waiver can provide skilled and non-skilled care leaving only the daily supervision of the person when Waiver providers are not in the home.

The concept behind Home and Community Based Medicaid Waiver is the provision of “choice” allowing the nursing home resident to live in the community rather than a nursing home. General eligibility requirements are:

  • Must have been in nursing home for 60 days.
  • Age 18 - 59.
  •  Florida Medicaid Eligible.
  • Able to live safely in the community with paid and unpaid supports coming from Waiver staff and the persons community support network available from family, friends and volunteers.                                               

Referrals can come from any source, usually from the individual, family, friends, other agencies or the nursing home where the individual resides. The Nursing Home Transition case manager completes an initial assessment, usually by phone. Persons willing to assist with the persons community based care are contacted and their participation is confirmed. Housing needs are also assessed prior to the first meeting with the individual residing in a nursing home. The Transition Coordinator schedules a meeting with the individual and a detailed assessment is completed. If there appears to be a reasonable expectation that Medicaid Waiver services along with community supports will meet the individual’s needs outside a nursing home setting, a plan for community reintegration is developed.

The community reintegration plan of care describes in detail the services needed to keep the individual safe and healthy in the community. The actual transition can take several weeks and the time for discharge can vary based on the persons needs. A comprehensive assessment of the home where the person will reside is completed. Home modifications are arranged and completed where necessary to assure the person accessibility and safety in the home. Service providers are contacted and a service schedule is completed. Necessary medical supplies and equipment, e.g. wheel chairs, bath aides and medical supplies, are authorized and a final discharge date is established.

At the time of discharge, the individual’s transition services are confirmed and the transition case manager then assumes the role of community based case manager. The Disability Achievement Center staff monitors the person in their community residence and is responsible for the ongoing case work needed to assure the persons well being in the community. These follow along supports are provided indefinitely or until the person can no longer safely remain in the community.

The Disability Achievement Center assists residents residing in nursing homes in Pinellas and Pasco Counties with an opportunity to be assessed for independent living through the Aged and Disabled Adult Medicaid Waiver Program. The Waiver provides intermittent care and supervision in a home and community based environment as an option to nursing home placement. The population targeted are those persons residing in nursing homes who have a community residence and an informal “non-paid” support network (usually family and friends) who are able and commit to provided some care and supervision to the person transitioning from nursing home to community living. The Waiver can provide skilled and non-skilled care leaving only the daily supervision of the person when Waiver providers are not in the home.

The concept behind Home and Community Based Medicaid Waiver is the provision of “choice” allowing the nursing home resident to live in the community rather than a nursing home. General eligibility requirements are:

·         Must have been in nursing home for 60 days.

·         Age 18 - 59.

·          Florida Medicaid Eligible.

·         Able to live safely in the community with paid and unpaid supports coming from Waiver staff and the persons community support network available from family, friends and volunteers.                                               

Referrals can come from any source, usually from the individual, family, friends, other agencies or the nursing home where the individual resides. The Nursing Home Transition case manager completes an initial assessment, usually by phone. Persons willing to assist with the persons community based care are contacted and their participation is confirmed. Housing needs are also assessed prior to the first meeting with the individual residing in a nursing home. The Transition Coordinator schedules a meeting with the individual and a detailed assessment is completed. If there appears to be a reasonable expectation that Medicaid Waiver services along with community supports will meet the individual’s needs outside a nursing home setting, a plan for community reintegration is developed.

The community reintegration plan of care describes in detail the services needed to keep the individual safe and healthy in the community. The actual transition can take several weeks and the time for discharge can vary based on the persons needs. A comprehensive assessment of the home where the person will reside is completed. Home modifications are arranged and completed where necessary to assure the person accessibility and safety in the home. Service providers are contacted and a service schedule is completed. Necessary medical supplies and equipment, e.g. wheel chairs, bath aides and medical supplies, are authorized and a final discharge date is established.

At the time of discharge, the individual’s transition services are confirmed and the transition case manager then assumes the roll of community based case manager . The Disability Achievement Center staff monitors the person in their community residence and is responsible for the ongoing case work needed to assure the persons well being in the community. These follow along supports are provided indefinitely or until the person can no longer safely remain in the community.