Station 1: Why are you here today?

I am here because I care about what I do and how I do it in transitioning individuals into community living.

To learn about resources for transitions

To learn more resources that are available for

community transitions

Planning to implement a lot with COPD (high risks + readmission). New ideas?

To learn and reflect-what do other people do that works well and I could do also?

To gain knowledge about transition resources avail

Station 1: Why are you here today?

To learn + exchange ideas to share what tools we have + hopefully learn more to become better with transitioning people

Exchange ideasDevelop and/or learn innovative strategies. How are others doing it

Learn how to better coordinate successful transitions from SNF’s

To networkTo increase my knowledge of resources for transitioning from program to another

Station 1: Why are you here today?

Network and learn more about community

Hear more about resources program in NC

To learn as much as possible to better asst my patients

To better learn a cohesive path to ensure smoother transitions for care & to learn!

To gain more insight on the transition process, also possibly network with other transition team leaders, to also take back some info to my facility to better meet the needs of population I serve (complex patients)

To learn how to overcome obstacles in transition process

Station 1: Why are you here today?

1. Interested in topics, i.e. Job/work 2. Increase referrals... for MFP

To learn more about transition planning, things I don’t already know, and learn from my peers

To become more effective as a transition coordinator

To increase my knowledge of comm resources

To hopefully learn ways/techniques to assist me when pts transition from one healthcare setting to the next

To learn more about resources available in the community for my residents who are discharging

Station 1: Why are you here today?

To learn & share strategies that will allow for smooth transitions to home & reduce readmissions

Additional info on transition

How to better assess which patients are likely to successfully transition into the community

To learn new skills, to present, and meet others that have a shared interest in helping individuals with I/DD and Autism

To gain the skills necessary to lead individuals & other professionals into successful transitions

Learn and grow

Station 1: Why are you here today?

To learn how D.C. Senior Services can play a role

in transitions

To learn resources to better assist community transitions

Learn, Share, Act

To gain better knowledge & resources for transitions

To learn as much about the MFP process, to be better at my job

To learn more info about the transition process

Station 1: Why are you here today?

Interested in being part of conversation to address needs of folk transition

Learn about more resources for people who are transitioning, learn how to engage family & guardians

Try to update peers of incredible fast pace of hospital difficulty of stress

To hopefully bring back some good community resources that will help myself and my co-workers in our discharge planning

Learn how to break down barriers w/ transitions process

To grow professionally, to learn, to network

Station 1: Why are you here today?

Learn others’ golden nuggets about best person-centered practices and applied to quality transitions into real community life

To put things in perspective

The potential to affect change

To be able to enhance my knowledge, improve our transitions care program, to expand in all care settings

Station 2: What facilitates (supports) transition efforts?

Communities Coordination Supporting the person’s goals

Getting input from the person who is transitioning

Resources & referrals

What team members can do & what their agency

can provide

Station 2: What facilitates (supports) transition efforts?

Transition coordinator/agency developing strong collaborative partnership

Effective communication b/w community base providers & hospitals Realistic expectations

Knowledge of sustainable supports

Collaborative work among agencies

Community effort-everyone on the same page working toward the same goal

Station 2: What facilitates (supports) transition efforts?

Staying person-centered Good action plan & someone they can call on

Open-minded, not imposing your belief values

Natural supports & invested team members Supportive family

Primary care

Station 2: What facilitates (supports) transition efforts?

CommunicationAdministrations that understand the process

A team of people who we can rely on! As a transition coordinator, I know some things- but need a good tam/network to ask questions

Team work among all players

Relationship and rapport with individual Good communication

between programs

Station 2: What facilitates (supports) transition efforts?

Person being open to next level of care

Other professionals understanding the

program (MFP, PACE) The needs of the person needing transition care

A positive attitude from all team members so that the person can be successful

Teamwork and open communication

The attitudes of the care worker & the individual

transitioning & knowledge of care

worker to resources available

Station 2: What facilitates (supports) transition efforts?

Addressing barriersUse of evidenced-based

practices across the continuum

Referrals & coordinating with resources for a successful transition

Good communication, available resources, patient/family buy-in/support

Involvement of durable medical providers, such as respiratory post D/C

Strong support system “family, church, friends, neighbors”

Station 2: What facilitates (supports) transition efforts?

Natural support, good plan developed with individual, monitoring and .... addressing barriers

Provider agencies, developmental centers & MCOs

Trust & relation support

Collaboration among supports

People who are willing to take risks!

Being a knowledgeable guide

Station 2: What facilitates (supports) transition efforts?

Positive attitude, wanting to learn, avail resources, be realistic and honest

Consideration of the whole person and identifying best and worst scenarios and planning for the most support possible

Good action plan & someone they can call on

Station 3: What are the barriers (hinders) to transition efforts?

Lack of staff with base community resources

Issues with school systems not being tolerant

No placements available for adults/children that can meet needs. Providers saying they have availability, capability, experience but don’t

Lack of knowledge of what each level of care can provide among providers

Lack of communication or warm hand off to community-based providers, hospitalization

Occasional lack of transparency

Station 3: What are the barriers (hinders) to transition efforts?

Political will to remove all the barriers

Lack of knowledge on possible purchasing a home

Need for additional technology rest assured

Money within communities to provide resources & FTEs

Not identifying needs prior to discharge, i.e. equipment, financial capability to pay for medicines etc.

No funds available within the time needed for services trying to access

Station 3: What are the barriers (hinders) to transition efforts?

Lack of resources

Willingness of the person to apply for

resources

Lack of resources, “transportation”,

housing

Medicaid deductible

Categories of support: there are always people who fall thru the cracks, don’t qualify-we need to be creative about making sure they have needs met!

Limited ICF (intermediate care facilit

y) vacancies

Station 3: What are the barriers (hinders) to transition efforts?

No insurance, self payNo primary care giver but trying to figure out how to access their rights

Lack of family/community

support

Low incomeLimited resources

Housing/criminal background before

disability

Station 3: What are the barriers (hinders) to transition efforts?

Home repairs Knowledge of resources, i.e. Home mod, housing

Organizational policies & procedures

Organizational policies & procedures

Transitioning pts from home to SNF and

haven’t seen MD in months/years

Rural areas with limited resources especially

transportation

Station 3: What are the barriers (hinders) to transition efforts?

Rural areas (lack of resources) Communications, lack of

technology in home

Wait time-transition process takes too long and they get frustrated

Lack of housing/support systems

Unrealistic expectation of person, lack of acceptable understanding of medical needs

Lack of finances, community support, and options

Station 3: What are the barriers (hinders) to transition efforts?

Lack of community, family support

Hospital not aware of community partners (if

person doesn’t tell staff)

Patient + medical team not having same goals

Lack willing or capable caregivers

Lack of transportation On-going criminal activities

Station 3: What are the barriers (hinders) to transition efforts?

Expectation from everyone involved

Not enough resources in my area, medics/Medicaid restrictions guidelines

Funding, lack of appropriate services, lack of insight, and motivation

Time frame for application approve assessment

Affordable/accessible housing, community-based personal assistant services, policy that limits individual choice

ACTT drift of mission over the years trying to partner, equip, encourage staff to join our “mission”

Station 3: What are the barriers (hinders) to transition efforts?

Station 4: Emerging principles

Work yourself out of a job Be creative-outside box Flexible

Crisis planning

If nursing home patient came from home that

was not safe/cannot go back

Optimistically honest

Station 4: Emerging principles

Resonates most, being optimistically honest-if people, family know, it’s better for them to plan

Assessment-building relationship

Optimistic honesty + education

Not chaotic or sluggish, keeping momentum going hard

Center is person & family

Participant in the middle (harder than it looks)

Station 4: Emerging principles

Individual is guiding the goals Empowering person to

take responsibility

Making LTC facilities know about transitions opportunities-for public too

Community-based services, housing, transportation, individual choice

Holistic perspective Put everything in place

Station 4: Emerging principles

Warm hand offs Collaborating with others

Relationship building with participant—family

Communication & other systems SS/DSS/AEC, etc.

Need to know continuity of resource knowledge & communication

Don’t have to be an expert in everything

Station 4: Emerging principles

TeamworkCommunication, funds, step out of the box, ...

There should be conversations with guardians/people about transition prior to making application. Sometimes when I come to initial meetings-the guardian/person has no idea why I am there and I have to awkwardly explain. There should be several initial conversations with the team prior to beginning the MFP process.

Tracking outcomes to provide evidence-based practices