 Key Issues for Successful
Transition
 Initial Meeting and Assessment
 Person-Centered Plan
 Housing
 Transportation
 Other Issues

Key Issues for Successful
Transition
1. Motivation
2. Length of Nursing Facility
Stay
3. Natural Supports

Key Issues for Successful
Transition
4. Eligibility for Support
 Michigan Protection and Advocacy
Services (MPAS)
 (800) 288-5923
5. Access to Housing

Key Issues for Successful
Transition
6. Positive reputation with agencies
7. History of utility bills paid on time
8. Strong credit

Key Issues for Successful
Transition
9. Family support and unity
10. No substance abuse history/behavior or strong record of recovery
11. Mental Health support

Key Issues for Successful
Transition
12. Guardianship
 Michigan Protection and Advocacy
Services (MPAS)
 (800) 288-5923

Initial Meeting and Assessment
 Purpose
 Allow a 3 to 4 hour time slot for transition staff
 Introductions
 Discuss the transition program
 Releases of Information
 Responsibility, Medical

 Working for an Area Agency on Aging
 Working for a different organization
 Importance of Level of care and financial status
 Identify financial resources

 Obtain copies of chart
 History and Physical
 Medication list
 Any Psychiatric evaluations
 Past week physician, nurses, OT, PT and social workers notes
 Admission Face Sheet
 Discuss basic housing needs

Initial Meeting and Assessment
 12 Issues related to successful transition
 Veteran status

Initial Meeting and Assessment
 Discuss Person-Centered Planning
(PCP)
 What it is
 Person-Centered Planning provides an opportunity for the consumer, his/her advocates, family, friends and other chosen allies such as professional staff to get a clear sense of the life goals and desires of the consumer including plans to transition back to the community.
 Who they want to help with plans (allies)
 What topics they do and do not want to discuss
 Meeting date and time

Person-Centered Planning
 Dreams
 Nightmares, concerns, or fears
 Independence
 Financial
 Safety
 Relationships
 Care Needs

Person-Centered Planning
 Goals and steps to achieve goals
 Assign tasks
 Consumer, family, staff, friends
 Set timelines
 Set up next meeting date

 Social Security
 Social Security Administration
(800) 772-1213
 Food Stamps

 If consumer already has home
 Make a home visit
 Accessibility and safety issues
 Household needs
 Durable Medical Equipment (DME) needs

 Subsidized Housing
 Supported Housing
 If housing is needed:
 Call apartment complexes
 On site visits
 Rental information
 Utility information
 Criminal background checks

 Bus Availability
 Paratransit application
 From nursing facility to own home or apartment

 Substance Abuse
 A listing of substance abuse regional coordinating agencies:
 http://www.michigan.gov/documents/CA_Contact_List_123511_7.pdf
 Mental Health
 A listing of all of the Community Mental Health Agencies: http://www.macmhb.org/directory/directory05-06.pdf
 Mediation
 A listing of Centers for Dispute Resolution in Michigan:
 http://courts.michigan.gov/scao/resources/other/cdrpcenters.pdf
 Financial Education
 For information on the local sites for Building Your Financial Future which provides financial education for people with disabilities go to:
 http://www.copower.org/AT/BYFFlocal.htm

 Guardianship
 For more information about Michigan Protection and Advocacy
Services go to their website: www.mpas.org
 Housing Information
 Directory of Subsidized Housing: http://www.mshda.info/housing/
 Corporation for Supportive Housing: 810-229-7712
 Social Security Administration website: www.ssa.gov
 Food Stamps
 A Listing of local Department of Human Services Offices can be found by going to www.michigan.gov/dhs and clicking on County
Offices on the toolbar on the left side of the page.

 Transportation
 A listing of all public transit providers in
Michigan can be found at the MDOT website:
 http://www.michigan.gov/mdot/0,1607,7-151-
9625_21607-31837--,00.html
 You can get to this link by going to www.michigan.gov/mdot select doing business from the list on the left side, select Passenger
Transportation on the left side of the page, and then select Public Transit Providers