Relocation Assistance and Discharge Planning

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Relocation Assistance and Discharge Planning

• State Of Wisconsin Board on Aging and Long Term
  Care
• Tom LaDuke
• Relocation Ombudsman Specialist
• Rachel Selking
• Regional Ombudsman

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Ombudsman

• An Ombudsman protects and promotes the rights of
  long term care consumers and works with
  residents, their families and facilities to
  achieve quality care and quality of life.
• An Ombudsman typically assists in resolving
  concerns and complaints, but can consult with
  facilities
• You can reach an Ombudsman by contacting
• Wisconsin Board on Aging and Long Term Care
• 1402 Pankratz Street- Suite 111
• Madison WI 53704
• 1-800-815-0015
• boaltc_at_wisconsin.gov
• http//longtermcare.state.wi.us

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Social Worker Best Practice Guidelines

• STANDARD 4. Program Functions
• Interpretation
• Specific social work functions may include, but
  are not limited to the following
• -Advocacy of appropriate care and treatment of
  residents through the development and
  implementation of policies, and the education of
  residents, staff and family regarding residents
  rights, as well as consultation with the
  long-term care ombudsperson
• -NASW standards for social work services in
  long-term care facilities page 14.

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(No Transcript)
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Role of the Regional Ombudsman

• A regional ombudsman has unfettered access to any
  residential care facility and can investigate
  complaints in long term care facilities to
  suggest solutions to resolve problems.
• The ombudsman can provide consultation to
  facilities and can speak to community groups
  about long term care issues.
• The ombudsman can help establish and work with
  resident and family councils.
• While not inspectors or regulators, the Ombudsman
  works with state and federal enforcement agencies
  to improve the residents quality of life at the
  facility.

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Role of the Relocation Ombudsman Specialist

• The relocation ombudsman specialists role is
  not unlike that of the regional ombudsman except
  that rather than being regularly assigned to a
  number of homes in a particular county, he works
  anywhere in the state where groups of residents
  are being moved either because the facility is
  being closed or its being rebuilt or remodeled.
  

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Implications for Having to Move

• Q Why would someone ever leave a
• nursing home?
• A Either because he or she wanted to or
• because he or she had to (or because of
• voluntary or involuntary discharge.)
• Relocation can be stressful in either case!

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Person Centered Discharge Planning

• A move can be exciting and exactly what a
  resident wants
• But because moving can be stressful, if not
  harmful, a home must take steps to minimize any
  possible negative impact
• The best way of accomplishing that is through
  careful planning and thorough preparation thats
  centered on the residents wants and needs

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Federal RegulationsORIENTATION and PREPARATION

• 483.12 (a)(7) Orientation for transfer or
  discharge. A facility must provide sufficient
  preparation and orientation to residents to
  ensure safe and orderly transfer or discharge
  from the facility.
• F204 Interpretive Guidelines 483.12(a)(7)
  Sufficient preparation means the facility
  informs the resident where he or she is going and
  takes steps under its control to assure safe
  transportation. The facility should actively
  involve, to the extent possible, the resident and
  the residents family in selecting the new
  residence. Some examples of orientation may
  include trial visits, if possible, by the
  resident to a new location working with family
  to ask their assistance in assuring the resident
  that valued possessions are not left behind or
  lost orienting staff in the receiving facility
  to residents daily patterns and reviewing with
  staff routines for handling transfers and
  discharges in a manner that minimizes unnecessary
  and avoidable anxiety or depression and
  recognizes characteristic resident reactions
  identified by the resident assessment and care
  plan.

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Social WorkerBest Practice guidelines

• Ethical Standards
• 1.15 Interruption of Services
• Social workers should make reasonable efforts to
  ensure continuity in services in the event that
  services are interrupted by factors such as
  unavailability, relocation, illness disability or
  death.
• -Code of Ethics of the National Association of
  Social Workers

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State Regulation

• DHS 132.68(5) SERVICES.
• Social services staff shall provide the
  following
• (c) Discharge planning. Assistance to other
  facility staff and the resident in discharge
  planning at the time of admission and prior to
  removal under this chapter

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Social Worker Best Practice Guidelines

• STANDARD 4. Program Functions
• Interpretation
• Specific social work functions may include, but
  are not limited to, the following
• -Facilitating residents safe integration into
  the community through interdisciplinary discharge
  planning and follow up services.
• -NASW standards for social work services in
  long-term care facilities page 15.

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Relocation Stress

• Relocation Stress is also called transfer trauma
  and defined as the combination of medical and
  psychological reactions to abrupt physical
  transfer that may increase the risk of grave
  illness or death.
• This stress can take on clinical features like
  signs of depression, anger and/or anxiety about
  the move and could result in sleep disturbance or
  change in eating patterns weight loss or gain.
  Frequent falls can occur in a new and unfamiliar
  environment.
• The best way to mitigate relocation stress is to
  prevent it by providing the resident with
  information, facilitating choice and involving
  him or her in thoroughly planning the move.
• Its understandably more stressful to be made to
  leave than to choose to move

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Measures to Minimize Relocation Stress

• Promptly inform the resident of the need to move
  and present an optimistic attitude by pointing
  out any positive aspects of the relocation
• Thoroughly assess the residents needs and
  preferences and discuss all available options for
  relocating
• Offer written information about options and
  provide tours. Provide an escort and follow up to
  see whether or not the resident liked the
  proposed new setting
• Allow the resident time to think on the matter
  and provide opportunities to ask questions or
  state concerns
• Listen to what the resident is saying and respond
  honestly. Resolve concerns promptly
• Honor preferences, allowing the resident to
  maintain control. Be flexible as plans can change
• Keep the resident informed throughout the
  planning process. Encourage the participation of
  friends and families

• Be prepared, be organized. Avoid chaos, provide a
  sense of security to the resident
• Maintain the residents daily routine throughout
  the planning process and the move to the new
  home. Make arrangements for telephone and other
  services including the notification of a change
  of address. Notify interested persons of the move
• Safeguard personal possessions, and help pack and
  move belongings. Involve the resident and family
  to set up the new room similar to the old room
• Help the resident become acclimated to their new
  surroundings by offering tours and assistance
  with unpacking. Consider having a welcoming
  committee, matching a staff member/volunteer with
  each individual
• Educate everyone about Relocation Stress -all
  staff members, residents, families, volunteers,
  friends
• Monitor for signs of Relocation Stress, never
  minimize or ignore these characteristics
• Offer support, be empathetic, visit often, and
  respect the individuals rights

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State and Federal RegulationsPROHIBITIONS

• DHS 132.53(2)(a) CONDITIONS.
• (a) Prohibition and exceptions. No resident may
  be discharged or transferred from a facility,
  except
• 1. Upon the request or with the informed consent
  of the resident or guardian
• 2. For nonpayment of charges, following
  reasonable opportunity to pay any deficiency
• 3. If the resident requires care other than that
  which the facility is licensed to provide
• 4. If the resident requires care which the
  facility does not provide and is not required to
  provide under this chapter
• 5. For medical reasons as ordered by a physician
• 6. In case of a medical emergency or disaster
• 7. If the health, safety or welfare of the
  resident or other residents is endangered, as
  documented in the resident's clinical record
• 8. If the resident does not need nursing home
  care

• 42 CFR 483.12 (a)(2) Transfer and discharge
  requirements.
• The facility must permit each resident to remain
  in the facility, and not transfer or discharge
  the resident from the facility unless
• (i) The transfer or discharge is necessary for
  the resident's welfare and the resident's needs
  cannot be met in the facility
• (ii) The transfer or discharge is appropriate
  because the resident's health has improved
  sufficiently so the resident no longer needs the
  services provided by the facility
• (iii) The safety of individuals in the facility
  is endangered
• (iv) The health of individuals in the facility
  would otherwise be endangered
• (v) The resident has failed, after reasonable and
  appropriate notice, to pay for (or to have paid
  under Medicare or Medicaid) a stay at the
  facility. For a resident who becomes eligible for
  Medicaid after admission to a facility, the
  facility may charge a resident only allowable
  charges under Medicaid or
• (vi) The facility ceases to operate.

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Preparation and Orientation

• 483.12 (a)(7) Orientation for transfer or
  discharge. A facility must provide sufficient
  preparation and orientation to residents to
  ensure safe and orderly transfer or discharge
  from the facility.
• May require more than one planning session
• Resident has a right to
• Be informed of available options
• Be involved in choosing alternate living
  arrangement
• Participate in the planning
• Facility needs to
• Review the need for relocation
• Discuss the effect of the move on the resident
• Develop and implement an individualized
  relocation care plan that also addresses the
  mitigation of any possible trauma associated with
  the transfer.
• Provide counseling regarding the transfer
• Provide opportunities, including transportation,
  for the resident to make 1-3 visits to potential
  alternate placement options
• Follow up with both the resident and the
  potential alternate living arrangement on the
  results of the visit

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State RegulationsDISCHARGE ACTIVITIES

• DHS 132.53(3)(b)
• 3. Transfer and discharge activities shall
  include
• a. Counseling regarding the impending transfer or
  discharge
• b. The opportunity for the resident to make at
  least one visit to the potential alternative
  placement, if any, including a meeting with that
  facility's admissions staff, unless medically
  contraindicated or waived by the resident
• c. Assistance in moving the resident and the
  resident's belongings and funds to the new
  facility or quarters
• d. Provisions for needed medications and
  treatments during relocation.
• 4. A resident who is transferred or discharged at
  the resident's request shall be advised of the
  assistance required by subd. 3. and shall be
  provided with that assistance upon request.

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Relocation Planning First Phase

• Holding a Conference to
• Review the need to relocate and the residents
  assessed needs
• Discuss available options for alternate placement
  and services
• Determine the residents preferences
• Developing and Implementing a plan for
• Making Referrals other providers, ADRC, etc.
• Facilitating touring new places
• Exchanging of information
• Following up
• Monitoring for stress
• (Seven days before this conference might be a
  good time to send a discharge planning conference
  notice)

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State and Federal RegulationsCOUNSELING and
CONFERENCING

• DHS 132.53(3)(b) Planning conference
• 2. Unless the resident is receiving respite care
  or unless precluded by circumstances posing a
  danger to the health, safety, or welfare of a
  resident, prior to any involuntary transfer or
  discharge under sub. (2) (a) 2. to 10., a
  planning conference shall be held at least 14
  days before transfer or discharge with the
  resident, guardian, if any, any appropriate
  county agency, and others designated by the
  resident, including the resident's physician, to
  review the need for relocation, assess the effect
  of relocation on the resident, discuss
  alternative placements and develop a relocation
  plan which includes at least those activities
  listed in subd. 3.

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Referrals and Linking with Other Providers when
the Resident is Publically Funded

• ADRC referral
• Screening for Functional and Financial
  Eligibility
• Options Counseling
• Enrollment Counseling
• Referral to FC-MCO, PACE/Partnership, IRIS
• MCO Enrollment
• Team Assignment
• Assessment
• Development and Implementation of the
  Member-Centered Plan
• Implications for collaboration with discharge
  planning.

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Local Contact Agencies are Aging and Disability
Resource Centers (ADRCs)

• The cap on Family Care funding and relocation
  from a nursing home
• Operational Practice Guidelines
• -Implementation of the Enrollment Cap for the
  Family Care., IRIS, PACE and Partnership Programs
  and Urgent/Emergency Enrollment Guidance
• -ADRC of Wisconsin (revised 07/21/2011)

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Family Care Cap Exceptions

• Relocations
• An individual interested in relocating from a
  nursing home, funded under the Medicaid Program,
  may be enrolled in one of the long term care
  programs without regard to the limitations of the
  enrollment cap under the criteria as defined in
  the 2011-13 biennial budget, section 9121 (1g)
  The Department may enroll an individual who is
  relocating from an institution into a long term
  care program without regard to the limitations of
  the enrollment cap if any of the following
  applies
• 1. The individual has resided at the
  institutional facility for at least 90 days.
• 2. The Department removes the individual from the
  institutional facility under section 50.03 (5m)
  (a) of the statutes.
• 3. The institutional facility is closing or
  relocating residents under section 50.03 (14) of
  the statutes.
• 4. The institutional facility is not licensed to
  operate in this state.
• 5. The individual is relocated due to an
  emergency, as determined by the Department.

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Section Q discussion

• Section Q item Q0500B
• Do You Want to Talk to Someone about the
  Possibility of Returning to the Community?
• The Right of the resident to community placement

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Social WorkerBest Practice Guidelines

• Ethical Standards
• 2.06 Referral for Services
• (b) Social workers who refer clients to other
  professionals should take appropriate steps to
  facilitate an orderly transfer of responsibility.
  Social workers who refer clients to other
  professionals should disclose, with clients
  consent, all pertinent information to new service
  providers
• -Code of Ethics of the National Association of
  Social Workers

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Process Reviewed

• Decision to move has been made
• Issue a Planning Conference Notice and Convene to
• Review need for relocation, continuing care
  needs and provider options to meet those needs.
• Discuss preferences and developed plan that
  includes making referrals and facilitating
  exploration (maybe tours, etc.)
• Assess any potential negative reactions to the
  need to relocate and planned to mitigate
• Develop and Implement a Relocation Plan to
  explore options
• Secure and Confirm Alternate Living
  Arrangements

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SUITABLE ALTERNATE LIVING ARRANGEMENTS

• Under most circumstances, a resident may not be
  involuntarily discharged unless an alternate
  living arrangement has accepted the resident and
  the alternate placement is arranged. A facility
  to which the resident is to be discharged must
  have accepted the resident for and in advance of
  the transfer, except in a medical emergency (or
  if the transfer is for nonpayment of charges
  after a reasonable opportunity to pay.) The
  written notice must state the location to which
  the resident is to be discharged.
• The written notice also must state the effective
  date of discharge. The resident may not be
  involuntarily discharged unless alternate living
  arrangements have been secured and the resident
  has been provided with sufficient orientation and
  adequate preparation.

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State RegulationsALTERNATE PLACEMENT

• DHS 132.53(2)(b) Alternate placement.  
• 1. Except for transfers or discharges under par.
  (a) 2. and 6., for nonpayment or in a medical
  emergency, no resident may be involuntarily
  transferred or discharged unless an alternative
  placement is arranged for the resident. The
  resident shall be given reasonable advance notice
  of any planned transfer or discharge and an
  explanation of the need for and alternatives to
  the transfer or discharge except when there is a
  medical emergency. The facility, agency, program
  or person to which the resident is transferred
  shall have accepted the resident for transfer in
  advance of the transfer, except in a medical
  emergency.

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Discharge Notice

• Every resident has a right and facilities are
  required to provide reasonable advanced written
  notice of any planned (involuntary) discharge.
• This notice is to be made to the
• resident
• authorized decision-maker,
• known family member (unless the resident requests
  that the family not be notified,)
• legal counsel
• residents physician
• The notice must be made in writing, and in a
  language and manner thats understood by the
  resident and others.

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DISCHARGE NOTICE TIMING

• The written notice should be made at least thirty
  days before the resident is to be discharged
  unless the continued presence of the resident at
  the facility endangers the health, safety or
  welfare of the resident or others, or should
  immediate transfer be required by the residents
  urgent medical need or should the residents
  health improve sufficiently to allow a more
  immediate transfer. The resident may be
  discharged at his/her request or upon the
  informed consent of the residents guardian.
• Should the resident elect to move sooner (than
  thirty days after alternate living have been
  made) then notice should be made as soon as
  practicable before the discharge.

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State and Federal RegulationsTIMING and CONTENTS
of the NOTICE

• DHS 132.53(3)(a) Notice.
• The facility shall provide a resident, the
  resident's physician and, if known, an immediate
  family member or legal counsel, guardian,
  relative or other responsible person at least 30
  days notice of transfer or discharge under sub.
  (2) (a) 2. to 10., and the reasons for the
  transfer or discharge, unless the continued
  presence of the resident endangers the health,
  safety or welfare of the resident or other
  residents. The notice shall also contain the
  name, address and telephone number of the board
  on aging and long-term care. For a resident with
  developmental disability or mental illness, the
  notice shall contain the mailing address and
  telephone number of the protection and advocacy
  agency designated under s. 51.62 (2) (a), Stats.

• 42 FR 483.12 (a)(5)
• Timing of the notice.
• (i) Except when specified in paragraph (a)(5)(ii)
  of this section, the notice of transfer or
  discharge required under paragraph (a)(4) of this
  section must be made by the facility at least 30
  days before the resident is transferred or
  discharged.

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DISCHARGE NOTICECONTENTS

• The written notice must state the reason for
  discharge , the location to which the resident is
  to be discharged and the effective date of
  discharge.
• The written notice must inform the resident of
  the right to appeal the discharge decision and
  explain how to appeal the action as well as with
  contact information (name, address and telephone
  number) for the nearest office of the division of
  quality assurance and for either the ombudsman
  program (Board on Aging and Long Term Care) or
  protection and advocacy organization (Disability
  Rights Wisconsin.)

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Federal Regulations NOTICE CONTENTS

• 42 CFR 483.12 (a)(6) Contents of the notice.
• The written notice specified in paragraph (a)(4)
  of this section must include the following
• (i) The reason for transfer or discharge
• (ii) The effective date of transfer or discharge
  (See below iii-vii)483.12 (a)(6) Contents of the
  notice.
• (iii) The location to which the resident is
  transferred or discharged483.12 (a)(6) Contents
  of the notice.
• (iv) A statement that the resident has the right
  to appeal the action to the State
• (v) The name, address and telephone number of the
  State long term care ombudsman
• (vi) For nursing facility residents with
  developmental disabilities, the mailing address
  and telephone number of the agency responsible
  for the protection and advocacy of
  developmentally disabled individuals established
  under Part C of the Developmental Disabilities
  Assistance and Bill of Rights Act and
• (vii) For nursing facility residents who are
  mentally ill, the mailing address and telephone
  number of the agency responsible for the
  protection and advocacy of mentally ill
  individuals established under the Protection and
  Advocacy for Mentally Ill Individuals Act.

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APPEAL

• The written notice must inform the resident of
  the right to appeal the discharge decision and
  explain how to appeal the action. No resident,
  having appropriately filed a written appeal, may
  be discharged until after the division of quality
  assurance has completed its review and has
  notified both the resident and the facility of
  its decision.
• The written notice must provide the resident with
  contact information (name, address and telephone
  number) for the nearest office of the division of
  quality assurance and for either the ombudsman
  program (Board on Aging and Long Term Care) or
  protection and advocacy organization (Disability
  Rights Wisconsin.)

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State RegulationsAPPEAL RIGHTS

• 132.53 (6) APPEALS ON TRANSFERS AND DISCHARGES.  
• (a) Right to appeal.  
• 1. A resident may appeal an involuntary transfer
  or discharge decision.
• 2. Every facility shall post in a prominent
  place a notice that a resident has a right to
  appeal a transfer or discharge decision. The
  notice shall explain how to appeal that decision
  and shall contain the address and telephone
  number of the nearest division of quality
  assurance regional office. The notice shall also
  contain the name, address and telephone number of
  the state board on aging and long-term care or,
  if the resident is developmentally disabled or
  has a mental illness, the mailing address and
  telephone number of the protection and advocacy
  agency designated under s. 51.62 (2) (a), Stats.
• 3. A copy of the notice of a resident's right to
  appeal a transfer or discharge decision shall be
  placed in each resident's admission folder.
• 4. Every notice of transfer or discharge under
  sub. (3) (a) to a resident, relative, guardian or
  other responsible party shall include a notice of
  the resident's right to appeal that decision.

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State RegulationsAPPEAL PROCEDURES

• 132.53(6)(b) Appeal procedures.  
• 1. If a resident wishes to appeal a transfer or
  discharge decision, the resident shall send a
  letter to the nearest regional office of the
  department's division of quality assurance within
  7 days after receiving a notice of transfer or
  discharge from the facility, with a copy to the
  facility administrator, asking for a review of
  the decision.
• 2. The resident's written appeal shall indicate
  why the transfer or discharge should not take
  place.
• 3. Within 5 days after receiving a copy of the
  resident's written appeal, the facility shall
  provide written justification to the department's
  division of quality assurance for the transfer or
  discharge of the resident from the facility.
• 4. If the resident files a written appeal within
  7 days after receiving notice of transfer or of
  discharge from the facility, the resident may not
  be transferred or discharged from the facility
  until the department's division of quality
  assurance has completed its review of the
  decision and notified both the resident and the
  facility of its decision.
• 5. The department's division of quality
  assurance shall complete its review of the
  facility's decision and notify both the resident
  and the facility in writing of its decision
  within 14 days after receiving written
  justification for the transfer or discharge of
  the resident from the facility.
• 6. A resident or a facility may appeal the
  decision of the department's division of quality
  assurance in writing to the department of
  administration's division of hearings and appeals
  within 5 days after receipt of the decision.
• Note The mailing address of the Division of
  Hearings and Appeals is P.O. Box 7875, Madison,
  Wisconsin 53707.
• 7. The appeal procedures in this paragraph do
  not apply if the continued presence of the
  resident poses a danger to the health, safety or
  welfare of the resident or other residents.

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Discharge Planning End Phase

• After a decision has been made and both the
  resident and potential alternate placement
  facility have agreed upon the residents
  transfer, a planning session should be scheduled
  to discuss the final details of the move
  including the kinds of assistance to be provided
  in moving the resident and his/her belongings and
  funds, and provisions for medications and
  treatments.

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State RegulationsDISCHARGE ACTIVITIES

• DHS 132.53(3)(b) 3. Transfer and discharge
  activities shall include
• a. Counseling regarding the impending transfer or
  discharge
• b. The opportunity for the resident to make at
  least one visit to the potential alternative
  placement, if any, including a meeting with that
  facility's admissions staff, unless medically
  contraindicated or waived by the resident
• _._._._._._._._._._._._._
• c. Assistance in moving the resident and the
  resident's belongings and funds to the new
  facility or quarters
• d. Provisions for needed medications and
  treatments during relocation.
• 4. A resident who is transferred or discharged at
  the resident's request shall be advised of the
  assistance required by subd. 3. and shall be
  provided with that assistance upon request.

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State and Federal RegulationsSUMMARY and PLAN of
CARE

• 42 CFR 483.20 (l) Discharge summary. When the
  facility anticipates discharge a resident must
  have a discharge summary that includes
• (1) A recapitulation of the resident's stay
• (2) A final summary of the resident's status to
  include items in paragraph (b)(2) of this
  section, at the time of the discharge that is
  available for release to authorized persons and
  agencies, with the consent of the resident or
  legal representative and
• (3) A post-discharge plan of care that is
  developed with the participation of the resident
  and his or her family, which will assist the
  resident to adjust to his or her new living
  environment.

• DHS 132.53(3)(c)Records. Upon transfer or
  discharge of a resident, the documents required
  by s. HFS 132.45 (5) (L) and (6) (h) shall be
  prepared and provided to the facility admitting
  the resident, along with any other information
  about the resident needed by the admitting
  facility.
• DHS 132.45(5)(L) Discharge or transfer
  information. Documents, prepared upon a
  resident's discharge or transfer from the
  facility, summarizing, when appropriate
• 1. Current medical findings and condition
• 2. Final diagnoses
• 3. Rehabilitation potential
• 4. A summary of the course of treatment
• 5. Nursing and dietary information
• 6. Ambulation status
• 7. Administrative and social information and
• 8. Needed continued care and instructions.

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Discharge Summary and Post Discharge Plan of Care

• Discharge instructions should include at a
  minimum
• the individuals preferences and needs for care
  and supports personal identification and contact
  information, including Advance Directives
• provider contact information of primary care
  physician, pharmacy, and community care agency
  including personal care services (if applicable)
  etc.
• brief medical history current medications,
  treatments, therapies, and allergies
• arrangements for durable medical equipment
• arrangements for housing
• contact information at the nursing home if a
  problem arises during discharge.

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Discharge Summary

• Discharge summary should include at a minimum
• the individuals preferences and needs for care
  and supports personal identification and contact
  information, including Advance Directives
• provider contact information of primary care
  physician, pharmacy, and community care agency
  including personal care services (if applicable)
  etc.
• brief medical history current medications,
  treatments, therapies, and allergies

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MDS Q0400 (Post) Discharge Plan

• The care plan should include
• the name and contact information of a primary
  care provider chosen by the resident, family,
  significant other, guardian or legally authorized
  representative,
• arrangements for the durable medical equipment
  (if needed)
• formal and informal supports that will be made
  available,
• the persons and providers in the community who
  will meet the residents needs
• the place the resident is going to be living.

42
Process Reviewed

• I. Issue a Planning Conference
  Notice and Convene to
• Review need for relocation, continuing care
  needs and provider options to meet those needs.
• Discuss preferences and developed plan that
  includes making referrals and facilitating
  exploration (maybe tours, etc.)
• Assess any potential negative reactions to the
  need to relocate and planned to mitigate
• II. Develop and Implement a Relocation Plan
• III. Secure and confirm Alternate Living
  Arrangements
• IV. Issue Proper Discharge Notice to
• Identify location and effective date
• V. Convene a Final Discharge Planning
  Conference to
• Discuss final details of move with resident,
  interested parties and even subsequent care
  and service providers

43
Social WorkerBest Practice Guidelines

• STANDARD 4. Program Functions
• Interpretation
• Specific social work functions may include, but
  are not limited to, the following assistance
  with
• placement and expectations for care
• inter- or intrafacility transfers
• re-establishing community living
• -NASW standards for social work services in
  long-term care facilities page 15.

44
Questions

45
Resources

• Discharge Planning Guidebook
• Nursing Home Residents Rights Booklet
• Relocation Stress Syndrome Brochure
• Samples of a
• Discharge Notice
• Discharge Planning Conference Notices
• Helpful websites
• http//longtermcare.state.wi.us
• http//socialworkers.org/practices
• http//cms.gov/CommunityServices

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CONTACT INFORMATION

• Rachel Selking
• Regional Ombudsman
• [phone]
• rachel.selking_at_wisconsin.gov

• Tom La Duke
• Relocation Ombudsman Specialist
• [phone]
• thomas.laduke_at_wisconsin.gov