Common use of Transition Planning and Transition Plans for People in Facilities Clause in Contracts

Transition Planning and Transition Plans for People in Facilities. 1. The State, through its community mental health providers and/or other relevant community providers, will provide each individual in NHH and Glencliff with effective transition planning and a written transition plan as set forth below. The written transition plan may be incorporated into the individual’s discharge summary and paperwork from NHH or Glencliff. 2. Transition planning will: (a) begin with the presumption that with sufficient services and supports, individuals can live in an integrated community setting; (b) be developed and implemented through a person-centered planning process in which the individual has a primary role and is based on the principle of self-determination; (c) include persons who have the linguistic and cultural competence to serve the individuals; (d) be based on each individual’s needs and not on the availability, perceived or actual, of current community resources and capacity; and (e) not exclude any individual from consideration for community living based solely on his or her level of disability. 3. The transition planning process will result in an effective written transition plan that: (a) sets forth in reasonable detail the particular services and supports, including their scope, frequency, and duration, that each individual needs in order to successfully transition to and live in an integrated community setting, whether or not a suitable community setting is currently available; such services and supports may include housing, transportation, staffing, mental health care, health care, and other professional services; (b) sets forth which persons and/or organizations have responsibility for delivering needed services and supports before, during, and after the transition; (c) sets forth the date the transition should occur, as well as the timeframes for completion of needed steps to effect the transition; (d) sets forth any barriers to transition to an integrated community setting and how to overcome them, if possible; and (e) sets forth a post-transition schedule of monitoring visits by community mental health providers to the new community setting to assess whether the needs of the individual are being met. 4. In developing the transition plans, the State will make all reasonable efforts to avoid placing individuals into nursing homes or other institutional settings. Before adopting a transition plan that places an individual in a nursing home or other institutional setting, the State must consider all possible alternatives and describe the steps it took to implement the alternatives. If the final transition plan results in placement of the individual in a nursing home or other institutional setting, the plan shall be used to identify the barriers to placement in a more integrated setting and describe steps the State will take to address the barriers. 5. Similarly, the State will make all reasonable efforts to avoid admitting persons with developmental disabilities to NHH, except where individuals’ acute psychiatric needs cannot be addressed in a more integrated service or treatment setting. If such individuals are admitted, the State will document the basis for their admission and immediately begin transition planning on their behalf, consistent with the requirements of Section VI. 6. The State will create a central team to assist in addressing and overcoming any of the barriers to discharge identified during transition planning and/or set forth in the transition plans. The central team will include personnel with experience and expertise in how to successfully resolve barriers to discharge including ACT team members, supported housing providers, and peers who work for community providers. 7. The State will design and implement a system for in-reach activities. The in-reach system will include meetings between individuals in NHH and Glencliff and the community mental health program or provider from their respective regions to develop relationships of trust and to actively support these individuals in transitioning to the community. The in-reach system will also include opportunities for meetings with the State and to obtain the State’s assistance in identifying and addressing barriers to community living. In conducting in-reach: (a) the State, through the community mental health program or provider will, among other things: i. explain fully the benefits of community living, including ACT, supported housing, and supported employment; ii. facilitate visits to community settings and accompany residents of these facilities on these visits; iii. explore and work to address the concerns of any individuals who decline the opportunity to move to a community setting or who are ambivalent about moving to a community setting; iv. review with reasonable regularity (at least quarterly), these individuals’ housing preferences and interest in community living; and (b) the State will: i. offer to meet with any individual and/or their guardian, if one has been appointed, that continues to express reservations about living in the community, to ensure that the individual and guardian fully understand the community living options; and ii. propose individualized strategies to address the individual’s or guardian’s concerns, provide opportunities to visit community programs, and facilitate conversations with providers about the services that will be available in the community and with individuals who have successfully transitioned from institutional settings to living in the community. 8. If an individual and/or guardian is opposed to a community setting, the State will document the steps taken to fully inform them of the community options and document the particular concerns that the individual and/or guardian has with moving to the community. The State will develop individualized strategies to address the individual’s or guardian’s concerns, to be discussed at future meetings. The State will establish a system for re-contacting these individuals and/or their guardians regularly, and at least annually, regarding their interest in community alternatives. 9. The State will identify individuals at NHH or Glencliff within the Target Population who have a dual diagnosis of developmental disability and mental illness and provide each individual with effective transition planning and a written transition plan as set forth in this section, using services and supports available from both the developmental disabilities and mental health services delivery systems to meet their needs.2 10. Any individual referred to Glencliff, whether from the community, NHH, or any other facility or hospital, will be reviewed pursuant to Pre-Admission Screening and Resident Review (PASRR), to determine if the individual has a developmental disability and/or mental illness and whether that individual’s needs could be met in the community with adequate and appropriate services and supports. These PASRR reviews will be conducted by qualified developmental disability and/or mental health professionals. If the PASRR review determines that the individual’s needs could be met in a community setting, the individual will be referred promptly to the appropriate Area Agency and/or Community Mental Health Center. Providers of developmental and mental health services will discuss and develop community options with the individual and will offer the individual appropriate services and supports in an integrated community setting.