"Moving Into the Community: Strategies to Help Individuals Make the Transition" Mike Auberger GETTING SOMEONE OUT OF A NURSING HOME OR OTHER INSTITUTION- SCENARIO 1. If no one contacts us ( a relative, a social worker, an aide, or a friend) with the name of a person who wants to get out of the nursing home then ------ 2. One of our organizers goes into the nursing home. They start talking to people at the front door. Many people hang around the front door to smoke as they say "What else have you got to do in a nursing home?" You can start a conversation immediately by offering them a cigarette, and a light. The organizer talks about how they used to be in a nursing home, but now they have their own place with attendant services. They ask the person if they like it in the nursing home, or had they ever thought about living in the community. Some people say they have someone getting them out. In that case we give them our card and say "Great! Good Luck! Call us if you need anything when you get out or if your help doesn't come through". Some people will say "I can't". You ask why. You can try to talk about being in that same situation, give suggestions, and leave them a card or brochure, tell them to call you, and look them up the next time you go. And some people will say "yes". The organizers will talk to them for a while, give them a card and brochure, and tell them to call for an interview, or someone will contact them for an interview. (Remember: some people have memory loss, they can't get to a phone, or they lose the card, or someone takes it.) So you must initiate the follow-up. Don't make promises you can't carry through with. 3. The interview We go to them, bring them to us preferably somewhere with some privacy from nursing home ears. We are very straight. We ask questions like what is their disability? How did it happen? When? What have you done since? Have you ever lived on your own since? What did you do before? Have you been married? Do you have any dependents? Where are they? Do you have a payee? A guardian? What will you do if you move out on your own? How will you spend your day? Do you have any money? What benefits are you on? Do you have anything to set up a house with? What kind of things will you need if you are living in your own apartment? There are no wrong answers to these questions. They only give you some insight about the person. If the person has told you they want to move out that is all you need. I have them sign a request for a TPQY from Social Security to have proof of their benefits. (Many people don't know what they are on or how much since the nursing home gets all but $30.00 of it.) If the person says the disability occurred because of alcohol or drugs you can ask if they are dealing with it. Again it only gives you insight. Your goal is to make this a successful move. Mental health issues are something else to look for. With both of these you can suggest supports for the person. If the person has a guardian, are they in support of this move? You need to communicate and verify this with the guardian. If they do not support it, is the person willing to go to court and get rid of this guardian? After all of this you can get specific and talk about what kind of attendant services and how much they will need. Use common sense and pad it to make sure they will have plenty. Can they manager their own money? Then you can talk about where they want to live and transportation (which normally we suggest learning to ride the bus.) We also discuss equipment like power chairs, hospital beds, life lines, and if they are happy with their doctor or would like to change. ATLANTIS COMMUNITY, INC. RE-ENTRY INTAKE FORM PART I Application Date: _________________ Name: ______________________________Address:__________________________ A. Mailing Address (if different) ____________________________________ . B. Previous Address (if less than 2years)____________________________ Telephone Number ________________________ DOB:______________________ PRIMARY/SECONDARY______ Birth Place: ______________________________ Disability:___________________ __________________________ Social Security # ________________________ Date Disability Occurred:______ PCP/PCP Phone #: ________________________ Medicaid # ________________ Medicare # : _____________________________ Medicare A ___Medicare B ___ Private insurance:_________________________ Other______________________ Guardian's name:_______________________. Phone#:________________________ Address::___________________________________________________________. Contact/follow up Advocate's Name/Organization #1 - date :______________________________________________________ #2 - date:______________________________________________________ # 3 - date:_____________________________________________________. METHOD/INFORMED 1. IN PERSON 3. TESTIMONY 5. BRAILLE 8. LANGUAGE inter 2. IN WRITING (BOOK) 4. VIDEO 6. INTERPRETER/SIGN I have been informed and understand that I have the right to live in the most integrated setting (my home/institutional setting). Signature:_______________________________.Date:_________________________ Guardian's signature:______________________. Date:_________________________ PLEASE CHECK ONE I am interested in living in the community. _____ I am presently not interested in living in the community. _____ Materials left:________________________________________________________________. additional comments on back: ATLANTIS COMMUNITY, INC. RE-ENTRY INTAKE FORM PART II BENEFITS: 1. SSI__________________________Amount_____________________________ 2. SSDI _________________________ Amount__________________________ 3. PAS _________________________ PAS Expiration Date _______________ 4. OAP _________________________ Amount _________________________ 5. AND _________________________ Amount ________________________ 6. HCA _________________________ Amount _________________________ 7. SALARY _____________________ Amount _________________________ 8. VA __________________________ Amount _________________________ 9. FOOD STAMPS Amount_________________________ _ 10. OTHER ______________________ Amount _________________________ SEX: M F Ethnicity (Optional) ___________________________________ Payee Name: ______________________________ Phone# ____________________ Address: ___________________________________ Marital Status: (Circle One) Single Married Divorced Widowed Separated Number of Dependents: ____________ Spouses Name: ___________________DOB: _________ SSN#: ________________ Address_______________________________Phone#_________________________ Dependent(s): Name: __________________________DOB: _________ SSN#: ________________ Name: __________________________DOB: __________ SSN#: _______________ Name: __________________________DOB: ____________SSN#: ___________ (If more than three - please list below) ATLANTIS COMMUNITY, INC. RE-ENTRY INTAKE FORM PART III Date/Location of Last Hospitalization: ____________________________________________ In case of emergency contact: Name/Relationship: _______________________________/_____________________________ Address __________________________________ Phone: ___________________ Name/Relationship: _______________________________/_____________________________ Address __________________________________Phone: ______________________ Previous Attendant Service: Name of Agency: _______________________________________________________________ Address: __________________________________ Phone: __________________ Services Desired: Attendant Visits _________ Medication Monitoring ______ Learning Center ____________ Housing ________ Financial Management _______ Grocery Shopping _________ Transportation Training _______ Benefits Coordination ______ Advocacy ____________ Other: ________________ SEE CHECK LISTS CHECKLIST FOR RELOCATION TO THE COMMUNITY 1. Did you make transportation arrangements? 2. Did you have all your prescriptions filled? 3. Do you have the name, address and phone number of your new physician? 4. Did you have your medical records forwarded to your physician? 5. Did you make an appointment with your physician during the first week of your relocation? 6. Do you have the names, addresses and telephone numbers of any specialists you may need? 7. Did you identify emergency numbers and backup help? 8. Do you have the name, address and phone number of your new dental clinic? 9. Did you notify the appropriate offices about your change of address? Social Security Office? Utility Companies? Magazines subscriptions? Post Office? Country Assistance Office? Paratransit? 10. Did you make arrangements for phone and utilities to be turned on? 11. Do you have all your essential household items? 12. Do you have the name, address and phone number of your new bank> 13. Do you have the name, address and phone number of your new pharmacy? 14. Do you have the name, address and phone number of your medical supply provider? 15. Did you arrange for attendant care or homemaker services and back ups? 16. Did you purchase or order all necessary adaptive equipment? CHECK LIST FOR NEW CLIENT IN THEIR HOME Name:_____________________________________________________________ Item: X: If not, What is needed: Supplies: Medications: Bowel Programs: When: Showers: When: Meal Preparations: Organizing: Working Phone Service: Working Utilities: Medical Equipment: If anything is missing, or needed, please return this form, or call the office immediately 303/733-9324 and talk to Babs, Frank, Tisha, or Cindy CHECK LIST FOR NEW CLIENTS HOME NAME: ______________________________________________________ Item: X: Item: X: Bed Food Kitchen Table Toilet Needs Television Paper Towels Phone Soap (Bathing) Pillows Toothpaste Blankets Laundry Soap Sheets Cups Towels Glasses Wash Clothes Furniture Dish Rags Trash Cans Trash Bags Broom Mop Vacuum Cleaning Supplies Dish Soap Plates Bowls Cooking Utensils Silverware