Care Transition Services. Contractor will provide transition services to Care1st members residing in skilled nursing facilities (SNF’s), rehabilitation hospitals, and acute-care hospitals that wish to transition into the community. An Independent Living (IL) Advocate will meet with the member at the facility where he or she resides to conduct an intake assessment, which determines if the individual can benefit from services. Once this determination is made, the IL Advocate will write up a Transition Care Plan with the member, and will work with Care 1st Case Management/Social Services and/or facility Discharge Planner/Social Worker to ensure a successful transition. If the member is residing in a SNF, rehabilitation hospital and/or acute-care hospital, the IL Advocate may potentially request California Department of Rehabilitation (DOR) transition funding for the consumer to assist with first month’s rent, basic furniture, and initial stock of groceries, basic household items, and Assistive Technology (AT) items, if needed. This funding is to be used to provide a basic “link” between institution and community. Contractor has, and will continue to develop, additional funding sources to assist with the transition process wherever possible. Working in collaboration with the member as well as Care1st and facility staff, Contractor’s IL Advocate will provide information and referral, peer counseling, and advocacy support to the consumer to assist in the discharge process. Examples of services provided include, but are not limited to housing resources (including; housing lists, housing connections as appropriate, e.g. Single Room Occupancy (SRO), Independent Living Homes and other affording housing units such as apartments), assistance with In-Home Supportive Services (IHSS) set up, assistance with application for paratransit services, mobility training, and benefits counseling. Contractor’s IL Advocates will provide information and support within the scope of their job to successfully transition Company’s members into the community. Once transitioned, the IL Advocate will continue to work with Company’s members to assist them in meeting the goals that they set in their ILP. Case Coordination & Monitoring Activities Contractor will develop an Independent Living Plan (ILP), in coordination with member, and will provide ongoing monitoring and care coordination, as needed. Contractor will submit all relevant information to Company via fax or another process, as agreed upon by the parties. C...
Care Transition Services. Contractor will meet individually with each Member to explain the program and the Participants’ Rights and Responsibilities, complete all necessary program enrollment paperwork, and develop the Comprehensive Service Plan (CSP) which is a team project involving the Member, family (optional), Company Case Management/Social Services and/or facility Discharge Planner/Social Worker and other Service Personnel to ensure a successful transition. Contractor will submit the CSP and all relevant information to Company via fax or other process, as agreed upon by the parties. All parties involved in the transition strategy approve and agree to the plan, before the transition begins. Based on the approved CSP, and the level of care required by the Member, a determination is made by the Contractor as to which Home and Community Based Services (HCBS) waiver services may be appropriate for each enrollee. Working in collaboration with the Member as well as Company and facility staff, Contractor will provide information and support within the scope of their job, and the CSP, to successfully transition the Member into the community. Examples include: (see Addendum 2) • Peer Counseling (Stepping Stones 10-week program) • Independent Living Skills Training • Assistive Technology and Device Lending/Loan Program • Housing/Personal Care Attendant Services • Advocacy Support Services *NOTE: Members who are receiving Community Transition Program Services, who are residing in a SNF or another LTC facility, who are at risk of institutionalization, or Members living in the community who are frequent users of high cost urgent care and short term hospitalization benefits for the lack of adequate LTSS, will be assisted by the Contractor through a variety of available sources to receive access to social supports and services in the community. Contractor may potentially request funding for these Members in following categories for successful and sustainable transition in the community: Rental deposit, First month's rent, Basic furniture, Initial stock of groceries, Basic household items, Assistive Technology (AT) items, and Home and/or Vehicle Modifications, if needed. Once transitioned, Contractor will continue to work with the Member to assist them in meeting the goals that they set in their Independent Living Plan (ILP) through Community Living Services (case management and monitoring activities).
