6122 Area to Area Transitions

Georgia State Seal

Georgia Division of Aging Services
Access to Services Manual

Chapter:

6000 Community Transitions

Effective Date:

Section Title:

Area to Area Transitions

Reviewed or Updated in:

MT 2015-02

Section Number:

6122

Previous Update:

Summary Statement

Transition Coordinators will cooperate to assist one another in the transition of an MFP Participant from one PSA to another PSA.

Basic Considerations

Transition Coordinators are called upon to assist MFP Participants in a person-centered process. This will require both TCs to communicate consistently. Information, including relevant documentation, must be communicated between TCs as soon as possible.

An official handoff of the case should occur on day of transition or shortly thereafter. This can be accomplished by a conference call. DAS staff must be invited to this call.

Definitions

Sending AAA

The Sending AAA or Sending TC refers to the PSA or staff in which the nursing home resides.

Receiving AAA

The Receiving AAA, or Receiving TC refers to the PSA or staff in which the Participant will eventually reside.

No exceptions at this time.

AAA Procedures

Pre-Transition

  1. Screening:

    • Sending AAA conducts MFP Screening as part of the Options Counseling process.

  2. Waiver Process:

    • Waiver referral is made through Options Counseling Process.

    • Sending TC assures appropriate waiver case managers and providers are selected. Make sure the providers operate in the geographic location in which the Participant wishes to move.

  3. Notification:

    • Sending TC assures the Receiving AAA is aware of the impending transition within ten (10) business days of screening. Sending TC assures DAS and Receiving TC obtain MFP screening once completed.

    • Sending TC sends separate communication to DAS identifying the Participant as a potential Area to Area transition at the time of screening submission.

  4. Housing Search:

    • Once the waiver determination is made, Sending and Receiving TCs partner on local housing search.

    • Receiving TC is responsible for assuring applications are submitted and housing application fees/security deposits are paid.

    • Receiving TC assists with establishment of utilities and payment of utility deposits.

  5. Individual Transition Plan:

    • Sending TC facilitates ITP in facility or location of Participant’s choice.

    • Sending TC notifies Receiving TC and DAS staff no less than ten (10) business days in advance of an ITP date.

    • Both TCs must work together to assure they participate in the ITP process.

    • Section 20 of each Area to Area ITP will be distributed to relevant partners (including DAS staff) within three (3) business days of the ITP.

    During the ITP, Section 20: Transition Plan Assignments, is thoroughly utilized. Section 20 delineates each task, person responsible, and due dates. Sending TC takes responsibility for updating the task list. If a responsible party delegates a task to someone else, the responsible party listed on the ITP will be held accountable for task completion in the appropriate timeframe.

  6. Medical:

    • Receiving TC assures a local physician, pharmacy, dialysis clinic, etc. are established prior to date of transition. It is imperative that an MFP Participant’s medical assurances are seamless throughout a transition.

    • Sending TC assures the nursing facility has ordered proper Durable Medical Equipment (DME), Assistive Technology (AT), etc. and items will be delivered to the agreed-upon address on or before date of transition.

  7. Final Notification:

    • Sending TC notifies all relevant parties (use ITP Item 20 distribution list as a reference) within seven (7) business days of the final transition date.

Day of Transition

  1. Transportation:

    • Sending TC coordinates transportation from the nursing facility to the Participant’s new residence.

  2. Documentation:

    • Sending TC obtains DMA-59 from the nursing facility and submits to DAS and the Receiving TC within three (3) business days of transition.

    • Receiving TC submits Discharge Day Checklist and waiver documents within the standards of promptness.

  3. Transition Services:

    • Receiving TC assures delivery of Household Goods and Supplies (HGS), Household Furnishings (HHF), and all MFP Transition Services identified at the ITP not attributed to the Sending TC.

  4. Social Security:

    • Receiving TC assures the Participant goes to the Social Security office with a copy of their executed lease (or other proof of address) and the DMA-59. Both documents will be required to assure the Participant receives their funds.

Post-Transition

  1. Face to Face Visit:

    • Receiving TC conducts face to face visit within seven (7) business days of transition.

  2. Contacts:

    • Receiving TC completes monthly contacts per MFP Policy & Procedure guide and delivers necessary Transition Services through the Participant’s MFP enrollment period.

    • At this point, Receiving TC takes full responsibility for MFP services and process.

  3. ITP Execution:

    • Receiving TC assures actions documented in ITP are executed in a timely fashion.

Transition Credit

Under the procedures above, the Sending AAA receives 0.25 transition credits and the Receiving AAA receives 0.75 transition credits.

References

  1. Policies and Procedures for Money Follows the Person, as published by Georgia Department of Community Health, Medicaid Division; dch.georgia.gov/georgia-money-follows-person-ga-mfp