Transition Coordination

The transition process requires the collaboration and coordination of many “moving parts” focused on meeting the individual needs, desires, and goals of the Take Me Home participant; all of which must fall into place on or immediately before transition day. TMH Transition Coordinators:

  • Work one-on-one with residents and their Transition Teams;
  • Accept and follow-up with referrals from the Aging & Disability Resource Network (ADRN);
  • Conduct face-to-face interviews with applicants to share information about options for returning to the community, including the availability of Waiver transition services;
  • Assess the resident’s readiness to begin the transition assessment and planning process;
  • Assess the resident’s transition support needs, including risk factors that may jeopardize a safe and successful transition to the community;
  • Facilitate the development of a Transition Team consisting of the resident, the Transition Coordinator, the Waiver Case Manager (A case manager is required for the Traumatic  Brain Injury Waiver (TBIW), a participant on the Aged and Disable Waiver (ADW) may choose to have a case manager or not), the resource consultant (for residents planning to self-direct their Waiver services), the Ombudsman (if applicable), the facility social worker and other appropriate staff and anyone else the resident chooses to include in the transition process;
  • Work with the resident and his/her Transition Team to develop a written Transition Plan which incorporates specific services and supports to meet identified transition needs (which may or may not become part of the Waiver Service Plan);
  • Conduct a Risk Analysis and develop a written Risk Mitigation Plan to address and monitor all identified risks that may jeopardize the resident’s successful transition, (which will become part of the Waiver Service Plan) and;
  • Arrange and facilitate the procurement and delivery of needed services and supports including, but not limited to, Waiver transition services prior to transition.;
  • Conduct outreach and serve as a liaison with nursing facilities to foster effective communication with facility staff and troubleshoot any issues that may create barriers to a safe and successful transition, and;
  • Work with the case manager and/or resource consultant on any identified needs post transition.

 

Transition Navigator Procedures and Forms

Transition Coordination Procedures Manual

Forms:
Intake Form
Transition Assessment Tool
Transition Planning Tool
Transition Assessment and Planning Readiness Verification
Risk Analysis and Mitigation Tool
24 Hour Emergency Backup Plan

Current Transition Coordinators:
Transition Coordinator Name
Contact Information
Counties Covered
Paula Corley
304-881-4623
Hancock, Brooke, Ohio, Marshall, Wetzel, Monongalia, Marion, Preston
Josh Phillips
304-380-2009
Jefferson, Berkley, Morgan, Hampshire, Mineral, Grant, Hardy, Pendleton
Autumn Hager
304-552-5524
Tyler, Doddridge, Harrison, Barbour, Tucker, Randolph, Upshur, Lewis, Doddridge, Ritchie, Pleasants, Wood, Wirt, Calhoun, Gilmer, Braxton, Webster, Roane, Jackson
Gina Fisher
304-807-3857
Mason, Putnam, Kanawha, Clay, Boone, Lincoln, Cabell, Wayne, Mingo, Logan
Sam Ball
304-922-1751
Nicholas, Pocahontas, Greenbrier, Fayette, Raleigh, Summers, Monroe, Wyoming, Mercer, McDowell
350 Capitol Street | Room 251 | Charleston, WV 25301 | Phone: (304) 558-1700 | Contact Us | Site Map