6211 Area to Area Transitions and Transfers | ACCESS-TO-SERVICES-5200-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
6000 Community Transitions |
Effective Date: |
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Section Title: |
Area to Area Transitions and Transfers |
Reviewed or Updated in: |
MT 2018-02 |
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Section Number: |
6211 |
Previous Update: |
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Summary Statement
Nursing Home Transition (NHT) Field Staff will cooperate to assist one another in the transition or transfer of an NHT Client from one Division of Aging Services (DAS) Planning and Service Area (PSA) to another PSA.
Basic Considerations
NHT Field Staff are called upon to assist NHT Clients in a person-centered process. This will require both teams to communicate consistently. Information, including relevant documentation, must be communicated between teams as soon as possible using the DAS Data System.
An official handoff of the case should occur on day of transition or shortly thereafter for Area to Area Transitions. This can be accomplished by a conference call, written communication (such as email) or an Alert Note in the data system. DAS staff may be invited to this call.
NHT Providers Procedures
Pre-Transition
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Screening: MDSQ Options Counselors complete the NHT Screening document
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NHT Referral Process: MDSQ OC refers to NHT Agency per regional agreements.
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Referral(s) Process: Outside referrals are made during the Transition planning process. Referrals are documented according to DAS Data System policy/procedure. Sending Team assists client and assures appropriate providers are selected. Make sure the providers operate in the geographic location in which the Client wishes to move.
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Notification:
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The Sending Team assures the Receiving PSA is aware of the impending transition within three (3) business days of NHT Screening
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Sending Team ensures DAS Data System is configured to allow Receiving Team access to the relevant client record.
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Housing Search:
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Once internal and external referrals are made, Sending and receiving Teams partner on local housing search (if necessary).
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The Receiving Team is responsible for assuring applications are submitted and housing application fees/security deposits are paid.
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The Receiving Team assists with establishment of utilities and payment of utility deposits.
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Care Plan:
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Any expenditure of NHT funds requires a Care Plan in the DAS Data System.
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Care Plans must be structured to justify the expenditure of NHT funds. Goal statuses must be maintained and accurate at all times.
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Refer to the NHT for Harmony Framework User Guide for additional instructions.
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For standard area to area transitions (day of transition), the Care Plan and budget should be clearly communicated between agencies, with responsibility for each line item (planned service) clearly delineated in the DAS Data System.
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Medical:
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The Receiving Team assures a local physician, pharmacy, dialysis clinic, etc. are established prior to date of transition. It is imperative that an NHT Client’s medical assurances are seamless throughout a transition.
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The sending Team 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 the date of transition.
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Final Notification:
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The sending Team notifies all relevant parties within seven (7) business days of the final transition date.
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Day of Transition
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Transportation: The sending Team coordinates transportation from the nursing facility to the participant’s new residence.
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Documentation: The sending Team obtains DMA-59 from the nursing facility and uploads to the DAS Data System within three (3) business days.
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Transition Services: The receiving Team assures delivery of NHT Transition Services identified by the Care Plan.
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Social Security: If the client’s income is dependent upon Social Security benefits, the receiving Team assures that the client can notify Social Security (this sometimes requires a face to face appointment at the Social Security office) of their transition.
Post Transition
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Face to Face Visits: Receiving TC conducts face to face visit within three (3) business days of transition and makes subsequent contacts per policy.
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Contacts:
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The receiving Team completes the post transition contacts per policy and delivers necessary Transition Services through the client’s NHT Enrollment period.
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At this point, receiving Team takes full responsibility for NHT services and process.
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Care Plan Execution: The receiving Team assures Needs/Goals documented in Care Plan are resolved in a timely fashion.
Transition Credit
Under the procedures above, the Sending PSA receives 0.25 transition credits and the Receiving PSA receives 0.75 transition credits. Shared transitions are only applicable to clients leaving a facility in one region and moving directly into another region. A client transitioning from a facility into a temporary home in the same region is not considered a shared transition, even if they eventually move to a permanent location in another region.
Post-Transition Transfer to Another Region
If a client moves to another region post-transition, the transition only counts for the original transition agency. This is not a shared transition. The original transition agency will retain budget responsibility for the client’s existing Care Plan. The transition agency in the region to which the client is moving will be responsible only for the required follow-ups during the client’s 365-day transition period. Any additional services requested under the NHT program must be approved by the original transition agency which maintains budget authority.
It is the responsibility of the original transition agency to communicate and facilitate the transfer of follow-up services to the new region/agency. All transfers should be documented in the DAS Data System using the Provider Enrollment and Alert Note functions.