STEP 1: Beginning the Planning Process - Linking a Person to the Community
It is important that people are linked to other people in the local community that can provide ongoing peer and/or citizen support. Possible places to start include a local Center for Independent Living, Citizen Advocacy Program or People First chapter. Some individuals may want to form a circle of support to assist in process of moving from an institutional setting to the community.
Some people know they want to leave the nursing home or institution and live in their own home or somewhere else. They need some help in understanding the steps to get there. Others may not know what is possible and over time, by getting to know you, will want to explore what is possible. Others may choose to stay where they are.
This kit provides you with some of the tools to help people get through the steps to obtain the “services” to live in the community. However, the work you do with the individual one-on-one is the crucial step to a person understanding what is possible. Some people may move quickly, others may have to wait for services. In the meantime, there is much work that can be done to link the person to the outside world, beyond the institution's four walls. It is also possible for a person to feel “institutionalized” living in a beautiful home in a neighborhood if he is not a part of the outside world.
In this section, we provide some tools to help you ask some questions, to figure out what has been done, what the person wants, what additional information is needed. These tools are only suggestions. You may find question that work better than the ones listed. Do what works best for you and the individuals you meet.
Tools:
Interview Form
Contact Lists for Possible Community Links (see Contacts section)
Introduction Interview Date:_____________
How did you get here? (nursing home or institution)?
Tell me about a typical day here. (What time you get you get up? Whom do you talk to? Who helps you during the day? What you do that you like? Don't like? What time you go to bed? etc.?
If you were to leave here, what things would you need help doing during a typical day? (What time would you get up? What would you eat? When would you eat? What would you do? Who would you like to see? Where would you go? What time would you go to bed? etc.)
Detailed Interview Date __/__/__
1. Person in Nursing Home/Facility:___________________________________
2. Social Security Number: ___/____/____ 3. Date of Birth: ___/____/____
3. Monthly Income: _________________
4. Source of Income:___________________________________________________________
_____________________________________________________________________________
5. Health Insurance: Medicaid / Medicare / Private Insurance / Private Pay
6. Do you have a guardian? : Yes / No / Don't Know
If yes, please provide the contact information for reaching the guardian:
Name of Guardian:______________________________________________________
Address:_______________________________________________________________
Phone: __________________________
What type of guardian do you have? : Person / Property / Don't Know
MORE INFORMATION ABOUT THE FACILITY:
1. Nursing Home/Facility's Name: ___________________________________________________
Address: ______________________________________________________________________
City:_________________________Zip:____________________Phone:_____________________
2. Doctor's Name: __________________________________________________________________
Address:________________________________________________________________________
Phone:_____________________________________
3. Facility's Social Worker's Name:___________________________________________________
Phone:_____________________________________
4. Reason for being in Facility/Disabilities:______________________________________________
________________________________________________________________________________
5. How long have you had the medical condition or disability?____________________________
6. How long have you been in this facility?____________________________
7. What did you do before entering the nursing home or facility?
Worked / Retired / School / Lived at Home / Other____________________
8. Where did you live before entering the facility? ______________________________________
9. When you went through the admissions process at the nursing home or facility, did anyone tell you about community-based options to living in this facility? Yes No
10. Did anyone give you a choice about living in the nursing home or living in the community with appropriate support systems? Yes No
HISTORY OF APPLYING FOR MEDICAID WAIVERS
1. Have you applied for a Medicaid Waiver Program? Yes No
2. If yes, which one?
Community Care Services Program (CCSP)
Independent Care Waiver Program (ICWP)
Mental Retardation Waiver Program (MRWP)
3. When did you apply? ___________________________________________________________
4. Do you have a copy of the application? Yes No
5. Who helped you with the application? ____________________________________________
6. Did you get a response? Yes No
If yes, what was the response? Accepted / Denied
Date of Response: ____/____/____
Do you have a copy of the letter?
If you were denied services or placed on a waiting list, did you appeal the decision?
Yes No
What happened?
If you did not appeal, why not?
7. In the last six months, has anyone from these community based programs
Called you on the telephone?
Visited with you at the facility?
Done an assessment of your needs?
If any of these apply, what happened?
8. Notes:
WHERE DO YOU WANT TO LIVE?
1. If you could live outside the nursing home or facility, where do you want to live?
By myself with some help
In a group home with a few other people
With a family member with some help
With a friend with some help
In a house or apartment with a roommate and some help
Other:__________________________________________________________
2. If you lived outside the nursing home or facility, are there people who could assist you? Yes No
If Yes, please list some of these people and their telephone numbers.
__________________________________________ ( ) _____ - _____________
__________________________________________ ( ) _____ - _____________
__________________________________________ ( ) _____ - _____________
3. With which activities do you require some assistance?
Bathing / Cooking / Toileting / Medication Management/ Transfers / Grooming / Transportation / Housekeeping / Dressing / Bill Paying / Other:__________________________
4. What are some of the reasons you want to live in the community?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
NOTES:
Phone: ( ) ______- __________________
Based on this person's interests, I will introduce him or her to . . .
Based on where this person wants to live or based on what this person wants to accomplish, I will introduce this person to . . .
Based on the skills or experiences this person wants to have, I can introduce this person to . . .
Based on the talents and gifts of this person, I can introduce this person to whom so he or she can teach, give, etc. to others?
Other Thoughts/Ideas:
(person wanting help) (person providing assistance)
at this address (of person providing assistance):
__________________________________________________________________
__________________________________________________________________
and to anyone else designated in writing by _________________________________________
(person providing assistance)
for the purpose of assisting me in securing home and community based services.
This release specifically includes any documents or records related to my medical condition, both mental and physical, my contacts and records with any medical facilities, providers, and professionals, and my contacts and records with any agencies, organizations, or individuals. This release includes, but is not limited to:
State of Georgia Division of MH/MR/SA
Regional Board (of county of residence of person being referred)
Community Service Board (list which one)
Division of Medical Assistance
Social Security Administration
Department of Rehabilitation Services
Division of Family and Children Services
Department of Human Resources
List all previous medical facilities as well as current facility: ___________________________________
Others:
and any person or entity with information about my circumstances or in possession of any of my records is authorized to release this information, to discuss my situation, and to make copies of written documents upon request, including documents secured from or provided by third parties.
All information will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect until the period necessary to complete all services provided by __________________________, or his or her designee, unless an expiration date is noted here: ______________________________________ .
______________________________________________________
Signature of Person Wanting Help and Social Security Number
______________________________________________________