Colberttransition Checklist

ColbertTransition Checklist

Member’s Name: RIN #:______
Planned Date of Transition: DOB: .
A comprehensive mitigation plan, completed medication list, and completed 24-hour back-up plan must be in place prior to transition.
Personal Identification and Changing Address
/ Task / Yes / No / N/A / Date

Obtain birth certificate and state ID

Change address on state ID and/or driver’s license

Change address with post office and voter registration

Change address with social security, bank, and financial institutions

Change address with the local office of the Department of Human Services (DHS),Medicaid, Medicare, and MCO plan

Notify nursing facility of new address

Caregiver Services
/ Task / Yes / No / N/A / Date

Determine which ADLs/IADLs will require assistance:

Bathing, dressing, and grooming:
Continence/toileting:
Ambulation/transfers:
Housekeeping/laundry:
Meal preparation/Cooking:
Shopping:
Scheduling appointments:
Telephone use:
Financial management:
Medication management:
Transportation:
Educate/coach member ADL/IADL skills

Determine level of family/social support for ADLs/IADLs

Identify community support services, including substance use groups, as applicable

Coordinate obtaining an updated DON assessment

Determine caregiver/homemaker service hours/per month

Identify agency/individual providing caregiver or homemaker service
Create caregiver/homemaker schedule including tasks and hours/days needed throughout the week
Request for caregiver to confirm completion of task by initialing when finished
Identify back-up caregivers and/or hire secondary caregiver, if needed
Request for caregiver to obtain training and Professional Caregiver Certification, if needed
Arrange for caregiver(s) to spend the first couple of nights with the member after transitioning into the community (if applicable)

Identify and arrange for other in-home services, ifneeded

List all providers and contact information on 24 Hour Back-Up Plan

Review 24 Hour Back-Up Plan with caregiver(s), homemaker and family/social supports

Environment/Housing
/ Task / Yes / No / N/A / Date

Determine need for handicapped/wheelchair accessible housing
Identify emergency exits at all identified housing locations. Assess the member’s ability to safely evacuate from housing, if needed.
Review plan with member and caregiver(s)

Acquire housing applications
Complete housing applications for rental assistance (if needed)

Submit housing accommodations letter (if housing becomes available and services still need to be arranged for member to safely transition)

Tour identified housing locations with the member
Determine need for home modifications (ex: grab bars, rails, ramp, etc.) and obtain approval
Send referral to UIC-ATU for evaluation and cost projection of home modifications needed
Secure bids and obtain approval for any additional housing needs identified
Have housing lease (if needed) signed by both the member and the landlord
Schedule/verify moving date
Obtain referral for physical/occupational therapy from nursing home provider. Arrange for physical/occupational therapy home safety assessment

Activate natural gas/electricity
Activate water service
Ensure member has heating and cooling systems
Obtain cellular/landline telephone service. Verify function and the member’s ability to correctly use the phone
Obtain EHRS system, if needed, and verify functionality.
Schedule installation/activation of phone service, television service, and EHRS (if needed)
Pay deposit for cable service (if needed)
Educate on importance of maintaining telephone/EHRS services after transition

Collaborate with the member and purchase furniture/ household items needed. Coordinate deliveryto the member’s post-transition home. Schedule moving assistance for furniture, if needed
Purchase groceries and have available on move in day

Educate/coach member on community resources such as grocery stores, pharmacies, libraries, police/fire stations, provider offices, walk-in clinics/urgent care center, hospitals, etc.

Finances
/ Task / Yes / No / N/A / Date

Confirm monthly income amount available post-transition
Identify date monthly income is available

Request budgeting/ financial management training as needed
Arrange education on paying rent/bills

Identify bank and account/services. Arrange automatic payment of bills

Identify and coordinate representative payee (if needed) and list them on 24 hour Back-up plan

Transfer SSI or SSDI payments to new address—
Communicate new bank account information if payments are made electronically, to Social Security.
Complete same procedure for retirement payments from social security

IMPORTANT NOTE:
If a person notifies SSA that they have returned to the community prior to the 22nd day of the month or cut-off date, his or her SSI will be reinstated on the first of the following month. If SSA is notified after the cut-off, the person will receive $30 on the first of the month and then a subsequent check making up the difference later on in the month. Full benefits will begin on the first of the next month.
Providers
/ Task / Yes / No / N/A / Date

Identify community Primary Care Provider (PCP) and verify services/care will be provided. Obtain location/contact information.
Coordinate first appointment with PCP to occur prior to Nursing Home discharge or within 1-2days of discharge.

Identify psychiatric provider(s)and resources in the community (if needed)
Verify the member’s eligibility to receive services/care from the psychiatric provider(s).
Schedule first appointment with psychiatrist to occur within two weeks of transition.

Locate accessible substance use treatment/support services in the community, if needed

Schedule intake appointment, if needed
Provide information to member
Educate on importance of abstinence and participation in treatment plan.

Identify specialty provider(s) in the community, if needed, including psychiatry, cardiology, oncology, podiatry, ophthalmology, dental, etc.
Identify specialty support services/clinics in the community: substance abuse, dialysis, wound care, heart failure, HIV, and palliative care
Notify member of appointment date/time

Identify accessible PT/OT services (if needed)
Schedule intake appointment if not previously scheduled

Determine need for home health care services (RN,OT,PT) and arrange, if needed
Determine date/time of first home visit and notify the member

Coordinate neurocognitive/neuropsychological testing to assess/monitor the members cognitive functioning for further evaluation of psychiatric symptoms, cognitive impairment, and/or neurological disorders

Educate the member on the importance attending and participating in first and all subsequent appointments for all identified providers.

Obtain contact information for all providers and list on 24 hour back up plan

Ensure member has written order for needed providers (PT/OT/ST, home health, etc.)

Ensure member has transportation to all appointments

Medication/Pharmacy
/ Task / Yes / No / N/A / Date

Identify community pharmacy
Locate a pharmacy to fill prescriptions on an ongoing basis.
Determine if pharmacy will deliver or if member needs to pick up medication
List pharmacy (and available second pharmacy) on the 24 Hour Back Up Plan
Submit letter to pharmacy 5 to 7 days prior to date of nursing home discharge

Medication reconciliation and organization
Assess/evaluate member’s current medication management skills
Coach/educate on medication management before transition
Determine how medication will be organized for member upon transition (pill box, pharmacy bubble packs, etc) and if member will require reminders for medication
Obtain updated medication list, ensure medication list is current at time of transition and obtain explanation of any changes.
Provide a copy of medication list to the member and review, identifying any concerns or discrepancies

Assist with obtaining prescription/ over-the-counter medications. Ensure member has all needed medication before transition
Schedule II Medications: Obtain written (active/valid) prescription. Determine plan for obtaining the monthly written prescription from the providerand how it will be delivered to the pharmacy
Collaborate with nursing home to have prescriptions written/available two days prior to transition
Obtain remaining medications from nursing home belonging to the member (show long-term care provider letter, if needed)
Ensure a sufficient supply of medications is available to prevent lapse in treatment post-transition. At least a 2 week supply of medication.

DME/Medical Supplies
/ Task / Yes / No / N/A / Date
Determine DME needed in community.

Walker/wheelchair/cane; over-lay bed mattress; hospital bed; commode; grab bars; shower chair/bench; hoyer lift; etc.
Verify DME required/utilized belongs to the member
Obtain DME, if needed, for items owned by nursing home. Assist member in obtaining orders from providers if needed.
Arrange delivery, verify functionality and safety of DME
Educate/coach on DME and safe use

Determine self-management supplies:

Locate home medical supply company to obtain supplies, including refills. List contact information/location on 24 Hour Back-up Plan.

Home blood pressure monitor
Scale
Glucose meter, diabetic testing supplies, insulin/syringes, sharps container
Oxygen/ portable oxygen, nebulizer machine, CPAP machine,
Incontinence pads; etc.
Order and ensure availability on move in day. Assist member in obtaining orders from providers if needed.
Ensure member knows how to use safely and effectively.
Educate/coach member on self-management skills

Transportation
/ Task / Yes / No / N/A / Date

Determine transportation options and availability (Access, First Transit, Bus application, etc.)

Determine transportation from nursing home to post-transition home

Obtain a “Disabled Person Identification Card” for public transportation

Educate/coach member on available transportation

List transportation providers on 24 Hour Back-up Plan

Medical Diagnoses and Illnesses
Task / Yes / No / N/A / Date

Obtain nursing home medical providerclearance/approval for transition

Obtain psychiatric clearance/approval for transition

Evaluate member’s stability. Recommend no hospitalizations/ED visits at least 6 months prior to transition

Collaborate with nursing home staff to initiate coaching/education on illnesses, medications, condition management, etc.

Advance Directives/Guardian
/ Task / Yes / No / N/A / Date

Assess for the presence of a guardian. Obtain documentation. Include the guarding on all decisions regarding transition

Assess for the presence of Advance Directives: Power of Attorney for Health Care; Power of Attorney for Finances/Property; Living Will; Do Not Resuscitate order. Obtain copies for member’s file and ensure member has a copy.

Educate on importance of Advanced Directives. Collaborate with family and NH Social Worker on initiating and developing this document.

Colbert Process /Documentation
/ Task / Yes / No / N/A / Date

Update CTS

Complete/update all MFP forms on CRM, if applicable

Complete the Quality of Life survey within one month before transition

Notify UIC-CON of potential transitions and submit documentation per the Colbert Case Review process.
Allow UIC at least 2 weeks to review the claims and paperwork and to develop the Case Review guide.

Complete and update the 24 Hour Back-Up Plan, identifying all supports and resources and contact information.

Complete/update risks/challenges/strengths form

Update care plan

Provide the member a copy of all Colbert forms

Discharge
/ Task / Yes / No / N/A / Date

Complete Discharge paperwork

Assist member in obtaining copies of NF records to provide to community providers
Assist member in obtaining all belongings from NF

Assist member with move and schedule home visit within 24 hours of transition

Additional MFP educational and process resources are available at:

See “Medication Notices” for additional information regarding obtaining medication, including “Refill Too Soon”