Based on the Initial Assessment, You Now Have the Opportunity to Work Together with Your

INDEPENDENT LIVING PLAN FOR NURSINGFACILITYTRANSITIONS

DEPARTMENTOFHUMANSERVICES MEDICALSERVICESDIVISION-MFP SFN539 (7-2014)

NameDate

This is YOUR IndependentLivingPlan.Itis importantthatthis planincludeanythingthatwill makeyour return homesuccessful. Youcanincludeanyoneonyour planningteamincluding your family,friends,your nursinghometeam, your countycasemanager, andyour transition coordinator. Youcanreview, add,or remove anygoals or services at anytime.

THINGSTOTHINKABOUTWHEN PLANNING YOUR RETURN HOME:

Wheredoyouwanttolive?

Whathelpwillyou needwith bathing,dressing, andusingthebathroom?

Whathelpwillyou needwithshopping,cooking, andlaundry?

Whathelpwillyou needwithyour medications?

Whatkind oftransportationwill you needwhenyoureturn home?

Whatkindsofthings doyouwanttodowithyourfamilyandfriends?

Doyouwanttogotowork, toschool,or dovolunteering?

WHATMAKESUPAGOOD INDEPENDENT LIVINGPLAN?

Writing it Down:Manythings need to be donebefore your move home.Writing themdown ina planwill help everyoneknowwhat needstobedone andwhowill be doingit beforeandafter your move.

Risk Planning:Risk planningis animportantpart ofreturninghome. Planning aheadwill prevent problemsfromdeveloping.This willmakeyoureturnhomesafer.

Back-up Planning:Youmayrunintounexpectedproblems whenyoureturn home.Makinga backup planis importantsoyouknowwho tocallwhen things donotgo as you planned.

STRENGTHSTO SUPPORT TRANSITION

WHAT ISMYMOVINGPLAN?

START / END
Iwill relocatefromthenursing hometothe communityof mychoice.

ThisdocumentwasdevelopedundergrantCFDA 93.779fromtheU.SDepartmentofHealthandHumanServices,CentersforMedicareMedicaidServices.However,these contentsdonot necessarilyrepresentthe policyof theU.S.DepartmentofHealthandHumanServices,andyoushouldnot assumeendorsementbytheFederalGovernment.

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HOWWILL ICOMMUNICATE MY CHOICES?

START / END
Iwill advocatefor myself.

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Iwill participate inthe discharge planningprocess
Iwill discuss mystrengthswith myplanning team
Iwill participate in self-advocacyskills training
Iwill participate in skillstraining to learn passive, assertive and aggressive communication skills
Iwill participate in skill trainingtolearnabout thegrievance processand howtofile acomplaint.
Iwill participate and advocate in dischargeplanning meetings
Iwill find outwhat mymedical diagnosesisandwhattypesofcare needed tostayhealthy

OUTCOMESUMMARYNOTES

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WHAT HELPDOINEED TO LIVEAT HOME?

BathingDressingEating
Personal HygienePreparingMealsMobilityInsidemy Home Using the Bathroom Shopping Money Management Housework TakingMedication Useof Telephone
LaundryTransportationMobilityOutsidemy Home
Getting in oroutof thebed/chair
START / END
Iwill have mypersonal careneedsmetwith support services.

WHATDO INEED TO DO TO REACHMYGOAL?

START / END
Iwill interviewand hire QSP’sorproviderbeforeleavingthe Nursing
Facilityand also backupQSP’s.
Find provider forskillednursing,ifneeded.
Completemonthlycalendarschedulefor QSP’s.
Establish adailyroutineofdutiesforQSPtofollow.
Reviewpossible informalsupports.
Explorehome care agencies and private QSP’s.
Obtainrepresentative payee services.
SetuphomedeliveredmealsorMealsonWheels

OUTCOMESUMMARYNOTES

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WHATARE MYHEALTH CARE NEEDS?

START / END
Iwill have myhealth care needsmet

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Establishpharmacyin the community
Obtain prescriptionsformedications after transition
Obtain prescriptionsfordailymedical supplies
Establish provider for medical supplies
Establishgeneral practice doctor
Establish specialtydoctor(psychiatry,wound care,diabetes, counseling)
Establish dentist in community
Establish eye doctor
Establish homehealthagencyservices
Publichealth services will be arrangedtoset-upmymedicationsweekly orbi-weekly

OUTCOMESUMMARYNOTES

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WHAT TYPES OF SPECIAL EQUIPMENT DOINEED TOLIVEATHOME?

START / END
Iwill obtain needed equipment and assistive technologyto use athome

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Obtainsummaryof OTevaluation (NFSWschedules).
Obtain prescriptionsfromDr. fordurable equipment.
Orderequipment through desired provider(usuallyafterdischarge).
Obtain assistive technologyassessment.
Reviewpossible informalsupports.
Explorefunding fortechnologyassessment and equipment.

OUTCOMESUMMARYNOTES

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WHATARE MYHOUSINGNEEDS?

START / END
Iwill live in a safe andaccessible homewith the necessaryresources
and services.

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Applyand obtain HUD housing subsidyforaccessible apartment.
Exploreand obtainfundingfor rent deposit andfirst month’srent.
Determineaccessibilityneeds throughOT eval/home eval.
Explorefunding forhome modifications.
Obtain abidforhomeaccessibilitymodifications.
Obtain householdfurnishings
Obtain phone service in home.
Obtain utilityhook-upsforhome.
Applyfor life-alertservices.
Completechangeofaddress atPost Office
Make surethere arefirealarms, carbonmonoxide detectorsandfire
extinguishers.

OUTCOMESUMMARYNOTES

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WHATARE MYFINANCIALNEEDS?

START / END
Iwill successfullymanage myfinancialresources.

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Prepareabudget to liveindependently.
Establish abankaccount.
Establish arepresentative payee atSocial Security.
Obtainsignaturestamp.
Contact Social Securityabout transitiontolive independentlyand set up
directdeposit.
Follow-up with Social Securityofficetoinsuretransition recorded and
checkarrives ontime.
Applyforcommodities.
Applyforweatherization.
Seekfunding forutilityhook-ups.
Applyforreducedphonerates.
Applyforfood stamps.
Applyformealson wheels.
Obtain energyassistance.

OUTCOMESUMMARYNOTES

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WHAT DO INEED TO PARTICIPATEINACTIVITIESOF INTEREST TOME IN THE COMMUNITY?

Activities thatareimportant tome:

Employment / Volunteeractivities / Education
Recreational transportation / Leisure interests / Communityactivities
START / END
Iwill participate in communityactivities of mychoice.
Iwill have accessible transportation inthe community
Iwillworkin ajob of mychoosing.

WHAT DO INEED TO DO TO REACHMYGOAL?

START / END
Choose recreational/leisureactivities
Obtain peervisitorforsocial participation
Participate inrecreational eventsofchoice
Join asupportgroup
Identifypeople with whomyou would like toremain in contactonce leaving thefacility
Identifysome of thepeople in thecommunitywith whomyou’d like to
reconnect.
Make application toDial-a-Ride.
Make application toSeniorRider, applyforsubsidy.
Speak with Communityfaith in action.
Learncitybus transportation system
Make arrangementsforaccessible transportation
Obtain powerwheelchairorscooter
Obtain permitorlicense.
Have adaptations doneto own vehicle foraccessibilityand functionality
Iwill participate in aclassofmychoice
Determineeducational opportunities
Participate inemploymentexploration/resources
Applyfor Vocational Rehab services
Researchandlearn aboutaPASS plan.
Learnaboutemployment resources

OUTCOMESUMMARYNOTES

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Thisdocument wasdevelopedundergrantCFDA93.779fromtheU.SDepartment ofHealth andHuman Services, Centers forMedicareMedicaidServices.However,these contents donotnecessarilyrepresentthepolicyoftheU.S.Department ofHealth andHuman Services, andyoushouldnotassumeendorsementbytheFederalGovernment.

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RISKPLANNING

Date
Risk Factors / Areaof
Concern / LocationonIndependent LivingPlan that
addresses risk planning
Substance Abuse
Items:48, 49, 50, 51,52,53,54, / YesNo
Mental HealthConcerns
Items: 37,38, 39, 40,41,42,43,47 / YesNo
BehavioralConcerns
Items:43,67 / YesNo
Cognition/Decision Making
Item: 4,66,67 / YesNo
Financial Concerns
Item: 15,22,23,24,25,26,27,28,32,33 / YesNo
LegalIssues
Item: 4, 5, 15,21 / YesNo
Fire Safety
Item:55,63,64 / YesNo
Falls
Item:55 / YesNo
Medication
Item:55 / YesNo
Nutrition
Item:55, 60, 61 / YesNo
Health Care Access
(Physician,Pharmacy, Home
Health,Dental,MedicarePart- D other) / YesNo
LivingEnvironment/Housing
Items: 6, 7, 8,9,10,11,12,13,14,15 / YesNo
Family/Informal Support
Items: 34, 35,36 / YesNo
Provider/Service Availability / YesNo
Treatment Compliance / YesNo
CommunityandSocial
Participation
Item: 19,20, 29,30,31,44, 45 / YesNo
Health Conditions
Item: 56,57,59,62,63, 64, 65 / YesNo
Other / YesNo
TeamMembers Present:

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SIGNATURE PAGE

Iaminagreement with the Independent LivingPlanlistedabove

Iam aware thatIwillbegivingupmynursingfacilitybedattime of discharge

Iam notinagreementwith this planand amaware of myrightto appeal by writingto: Appeals Supervisor

N D Department ofHumanServices

600E.Boulevard Ave.Dept325

Bismarck, ND 58505-0250

Consumer / Date
Family Member / Date
TeamMember: / Date
TeamMember: / Date
TeamMember: / Date

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