6217 Nursing Home Transitions Taxonomy of Services | ACCESS-TO-SERVICES-5200-MANUAL

Loss of housing during an inpatient facility stay is a primary reason for institutionalization. This service may be used to pay basic rent and utilities for a client’s residence for a 30-day period. This Service can only make payments for dates in which the client resides at an inpatient facility.

Required Documentation:

Should the NHT client require a different housing arrangement than prior to their stay at an inpatient facility, NHT Services may be used to pay setup fees and/or deposits for new utility services.

Required Documentation:

Should the NHT client require a different housing arrangement than prior to their stay at an inpatient facility, NHT Services may be used to pay security deposits, application fees, background check fees, and first month’s rent, plus any pro-rated rent for a partial month, for a new rental residence.

Required Documentation:

Many clients who transition from nursing facilities require functional supports to remain independent. NHT Services may be used to purchase medical equipment and/or assistive technology to support the individual’s independence. Should the client require assessment for specialized equipment or AT, NHT Services may assist with associated fees.

Should the client require a start-up supply of disposable supplies, such as incontinence supplies, sterile gloves, diabetic supplies, etc. NHT Services may purchase up to a 30 day supply of each item needed. NHT Services should not be used to support the purchase of any ongoing service.

Many NHT clients transition from an inpatient facility with changed functional needs. As such, NHT Services may assist the client with modifications to their home environment to make it more accessible to them or to increase their independence. Should the client require Environmental Modifications, the home must be inspected or assessed prior to modification. The inspection or assessment must produce a scope of work from which a quote or bid may be obtained.

EMD Inspection: Must be completed by a licensed contractor, certified home inspector, or Certified Aging in Place Specialist. Entity completing the inspection may not place a bid on the same job for which they are the inspector.

An inspection and scope must be obtained prior to use of this service. This service may not be used to modify Personal Care Homes.

NHT Services may be used to transport clients’ belongings from the inpatient facility or a storage location to their community setting. Moving Expenses may also be used to cover shipping/delivery costs associated with procurement of NHT Services.

Vehicle adaptations should only be funded for NHT clients when the adaptations are essential for regular transportation needs to support the participant’s independence. Vehicle adaptations must be identified as a transition barrier (because the client will not be able to access ongoing healthcare, etc.) and added to the Care Plan prior to discharge. Vehicle adaptations may not be added to the Care Plan post-discharge.

Personal Support Services for NHT clients may only be used during the initial transition from the facility back and is limited to 21 dates of service in the initial 30 days post-transition. This service should be used to support safe transition back into a community setting.

Personal Support Services provides assistance such as light housekeeping, running essential errands, and basic personal care needs (feeding, dressing, bathing, toileting, and transferring).

Many national associations, nonprofits, and governmental entities provide peer support and/or peer counseling for individuals with disabilities. NHT clients can receive visits and/or counseling from these providers and NHT Services can cover the associated fees. It is preferred that Peer Support is delivered face to face but may be delivered remotely.

NHT clients may request or require training or coaching to recover, re-learn, or reinforce skills needed to maintain their independence. Life Skills Coaching may be used to provide training that would support the individual as they reorient themselves to community living. This service may include, but is not limited to:

Caregivers for NHT clients may experience life changes and stresses that can jeopardize the success of a transition. NHT clients who are dependent upon a live-in, unpaid, caregiver are eligible for this service. Caregiver support services can include services similar to Life Skills Coaching and Peer Support (but directed at the caregiver) or more traditional Caregiver Supports, such as those delivered by Area Agencies on Aging.

Clients returning to the community may require new or updated household items such as kitchen supplies and equipment, furniture, bathroom supplies/toiletries, etc. NHT Services may be used to assist with setup of a new residence, or re-establishment of an existing residence.

This service should be limited to items that are required to facilitate independence and the ability to execute basic living standards. Items that are purely decorative or non-functional in nature are not to be purchased. Items that are for entertainment should not be purchased; traditional “entertainment” items (such as televisions, DVD players, etc.) being purchased to function as Assistive Technology should be coded to the Assistive Technology category and should function as assistive technology by allowing direct, two-way communication with other individuals or organizations. Radios may be purchased under the Household Setup category for listening to the news and/or receiving weather alerts.

Food/Meals: The Household Setup category may be used for an initial setup supply of food. This may include standard groceries or home delivered meals services. This subservice may not exceed $250 in cost.

This service may be used to transport NHT clients in the following ways:

Department of Human Services transportation vendors are a preferred vendor for this service.