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Transitions Planning

  • Community housing admission considerations

    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 MCO 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
  • Housing options and descriptions
  • Best practices for ongoing care and transitional planning
    • Ongoing scheduled meetings with MCO (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 (MCO) or family
      • Schedule meetings with MCO/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
  • Acute Transition

    Gundersen Health System

    Mayo Clinic Health System - Franciscan Healthcare

Date Last Updated: 06/03/2019 11:15 am