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 Coordinator​ 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