Transitions Planning

Facility standard assessment

• What are facility specialty areas and limitations?
• Discuss funding options
  • Community agencies
  • Eligibility requirements
• Share Community Touring Form
• Discuss family expectations
  • Level of care
    • Ratio of non-licensed staff
    • Is a skilled RN available and frequency?
  • Being realistic of finances up front
    • How much commitment financially is needed
    • Deposit up front
    • Private pay usually requires minimum of two years of funding
• If WI Medicaid long-term care program member, request member centered plan
• Inquire if Healthcare POA and Financial POA has been completed (if not, please complete)
• Forward documents to Health Information Management at hospitals

Community Housing

• Ongoing scheduled meetings with WI Medicaid long-term care program provider (if dementia diagnosis, meet more frequently)
• Increase meetings with frail elderly to ensure transition planning is occurring
• Completed Healthcare POA and Financial POA sent to area hospitals
• Document family meetings
  • First/last names who was present
  • Indicate if family or agency representative
• Attempt to have consistent staff interacting with residents
• Change in condition:
  • Discuss with funding source (WI Medicaid long-term care program provider  or family)
  • Schedule meetings with WI Medicaid long-term care program provider/family to discuss increased needs
  • Does Healthcare POA need to be activated?
• Provide a "pre" 30 day notice, prior to actual 30 day notice (sharing earlier than 30 days provides family time to move through their acceptance)
• "Blue" ER Transfer Form - a best practice form to help transition your patient into acute care and back to facility
  • Prep general information areas
  • Form available in person’s medical file

Gundersen Health System

Mayo Clinic Health System - Franciscan Healthcare (info being updated)