Training for Transition Coordinators Kim Donica and Laurie Damon Office of Ohio Health Plans Ohio Department of Job F

1. Training for Transition Coordinators Kim Donica and Laurie Damon Office of Ohio Health Plans Ohio Department of Job & Family Services

2. Referral Process Referrals to Home Choice ODJFS 02361 Can come from a variety of sources including: Consumers Family Members Advocates Nursing Facilities AAA’s CIL’s Pull up referral formPull up referral form

3. Referral Process The ODJFS 02361 is submitted to ODJFS Home Choice Intake and Care Coordination Unit (HCICCU). The HCICCU reviews and determines which waiver would most appropriately meet consumers needs. The HCICCU then sends the referral to the appropriate waiver entity for both a waiver and HOME Choice eligibility determination.

4. Referral Process The ODJFS HCICCU sends the consumer the HOME Choice Consumer Handbook. Contains: Welcome Letter Information about eligibility and qualified residence Due Process Information Relocation Workbook

5. HOME Choice Eligibility Requirements OAC 5101:3-51-02

6. Eligibility To participate consumers must: Reside in NF, ICF/MR or hospital for at least 6 months Stay must be continuous Can include a combination of NF, ICF/MR or hospital stay If at time of assessment the consumer does not meet this requirement, but it is anticipated they will prior to discharge, the consumer could still be eligible for program.

7. Eligibility To participate consumers must: Be receiving Medicaid benefits in the institutional setting for at least 30 days prior to discharge. Consumers may be admitted to facility under a different funding source and switch to Medicaid during the course of their stay. As long as 30 day requirement met, consumer would meet this eligibility requirement.

8. Eligibility To participate consumers must: Be receiving Medicaid benefits in the institutional setting for at least 30 days prior to discharge. If the consumer does not meet this requirement at the time of assessment, but it is anticipated that they will prior to discharge, the consumer could still be eligible for the program.

9. Eligibility To participate consumers must: Meet an Institutional Level of Care (SLOC, ILOC, ICF/MR LOC) For purposes of HOME Choice only, ODJFS is presuming level of care. Consumers do not have to be waiver eligible in order to participate in program.

10. Eligibility To participate consumers must: Relocate to a qualified residence A home owned or leased by the consumer or family member An individually leased and lockable apartment rented by the consumer or family member A community-based residential setting with no more than four unrelated persons

11. Eligibility Home Choice is built on Ohio’s existing system of services and supports. HOME Choice participants will be enrolled on either: One of Ohio’s existing HCBS programs or State Plan Services

12. Eligibility The case manager recommends a qualified program of services and supports (either waiver or state plan); or recommends denial of HOME Choice program.

13. Eligibility Approval for program cannot occur until consumer actually is discharged from facility and moves into qualified residence. HOME Choice Participation has three distinct periods Pre-Transition Period (period of time where activities occur prior to moving to community) Demonstration Period (begins the date of discharge and runs 365 calendar days) Post-Demonstration Period (begins day 366 after discharge from facility)

14. Transition Coordination If a consumer appears to be eligible for the HOME Choice program, the case manager assists the consumer in choosing a Transition Coordination Provider. List of Transition Coordination Providers by county Consumer has free choice of provider List of TC provider’sList of TC provider’s

15. Transition Coordination Once a consumer chooses a Transition Coordination provider, the case manager completes the HOME Choice Demonstration and Supplemental Service Plan indicating the chosen Transition Coordination Provider.

16. Transition Coordination Transition Coordination is authorized on the HOME Choice Demonstration and Supplemental Service Plan by the case manager. Show planShow plan

17. Eligibility Determination The ODJFS HCICCU: Reviews and enters information into the HOME Choice tracking system. Verifies Medicaid eligibility and institutionalization dates. Sends a letter notifying consumer of their preliminary approval for their program (pending a move to a qualified residence). Waiver administrative agency cc’d on letter

18. Eligibility Determination The ODJFS HCICCU: Contacts the identified TC provider and verifies their willingness/ability to provide transition coordination services to the consumer. Authorizes the payment of the first deliverable to the Transition Coordination provider. Notifies the case manager of the TC providers acceptance of referral and initiation of TC services.

19. Eligibility Determination The ODJFS HCICCU: Sends a copy of the HOME Choice Demonstration and Supplemental Service Plan to the Transition Coordination Provider.

20. Enrollment Once consumer moves from facility into the community the case manager completes the HOME Choice Enrollment Form and sends to the ODJFS HCICUU.

21. Enrollment The ODJFS HCICCU: Notifies the consumer and the state waiver administrative agency in writing of consumer’s enrollment on HOME Choice. Starts the 365 Demonstration Period clock.

22. Enrollment Consumer is enrolled on waiver or state plan and HOME Choice and services begin.

23. Questions?

24. HOME Choice Services and Supports OAC 5101:3-51-04

25. Services Three Categories of Services: Qualified Services Demonstration Services Supplemental Services

26. Services Qualified Services Existing waiver and state plan services Available during the both the demonstration and post demonstration periods. Eligible for enhanced federal match.

27. Services Demonstration Services Available only during the 365 day demonstration period (except for transition services i.e. goods and services that can be accessed during the pre-transition phase). Eligible for enhanced federal match. Authorized on the HOME Choice Demonstration and Supplemental Service Plan.

28. Services Demonstration Services HOME Choice Demonstration Services include: HOME Choice Nursing (except for ODJFS-administered waiver consumers) Independent Living Skills Training (except for ODMR/DD-administered waiver consumers Community Support Coach

29. Services Demonstration Services HOME Choice Demonstration Services include: Social Work Counseling (except for ODMR/DD waiver and PASSPORT consumers) Nutritional Consultation (except for ODMR/DD waiver and PASSPORT consumers) Community Transition Services (except for PASSPORT consumers)

30. Services Demonstration Services HOME Choice Nursing Defined at intermittent nursing in amounts greater than what is available via the state plan (intermittent nursing > 14 hours). May receive up to 44 hours a month.

31. Services Demonstration Services Independent Living Skills Training Training focused on: Financial Management Skills Social Skills Development Health Management Skills Home Management Skills Personal Skills Community Living Skills

32. Services Demonstration Services Independent Living Skills Training May receive up to 144 hours during the 365-day demonstration period (in individual, group or classroom setting).

33. Services Demonstration Services Community Support Coach An individual who provides guidance, education and works to empower the consumer, authorized representative and family members.

34. Services Demonstration Services Community Support Coach shall assist the consumer in: Making informed independent decisions Setting and achieving short and long term goals Identifying options and problem solving Managing multiple tasks

35. Services Demonstration Services Community Support Coach May receive up to 72 hours during the 365-day demonstration period

36. Services Demonstration Services Social Work Counseling Service to the consumer, authorized representative and/or family member on a short term basis to promote the consumer’s physical, social or emotional well being. Designed to promote the development and maintenance of a stable environment for the consumer.

37. Services Demonstration Services Social Work Counseling Can include: crisis intervention, grief counseling and other social service interventions that support the consumer’s health and welfare. Does not include: case management services.

38. Services Demonstration Services Social Work Counseling May receive up to 36 hours during the 365-day demonstration period

39. Services Demonstration Services Nutritional Consultation Provides 1:1 nutritional guidance to consumer’s with special dietary needs. Includes the development of a nutrition intervention plan.

40. Services Demonstration Services Nutritional Consultation May receive up to 36 hours during the 365-day demonstration period

41. Services Demonstration Services Community Transition Services (Goods & Services) Goods and services that will assist in a consumer’s successful transition into the community.

42. Services Demonstration Services Community Transition Services (Goods & Services) Does not include: Experimental or prohibited treatments Cost of room and board Uniforms and memberships Electronics used for entertainment purposes Cable/internet access

43. Services Demonstration Services Community Transition Services (Goods & Services) Up to $2,000 available per consumer

44. Services Supplemental Services Include: Service Animal Communication Aids Transition Coordination Available only during the 365 day demonstration period (except for Transition Coordination)

45. Services Supplemental Services Service Animals May include but are not limited to: Seeing eye dogs Hearing dogs Service monkeys

46. Services Supplemental Services Service Animals Includes: First years costs associated with the raising of the animal Housing, feeding, upkeep and medical care of the animal during training Actual training of the animal, student training, and related transportation, room/board and administrative activities Equipment and Supplies

47. Services Supplemental Services Service Animal Up to $8,000 ----one time maximum

48. Services Supplemental Services Communication Aides Includes: Augmentative Communication Devices or Systems Computers and Computer Equipment Other Mechanical and electronic Devices Cable and Internet Access Cost of Installation, Repair, Maintenance and Support of Any Covered Communication Aide

49. Services Supplemental Services Communication Aides Up to $5,000----one time maximum

50. Services A list of eligible provider’s for each demonstration and supplemental service will be provided at later date.

51. Service Planning The case manager determines the type and amount of demonstration and supplemental services that are needed. All HOME Choice Demonstration and Supplemental Services must be authorized by the case manager on the HOME Choice Demonstration and Supplemental Service Plan.

52. Service Planning The HOME Choice Demonstration and Supplemental Service Plan must be sent by the case manager to the ODJFS HCICCU. THE HCICCU then forwards the HOME Choice Demonstration and Supplemental Service Plan to the FMS. The provider submits claims to the FMS and the FMS pays the provider.

53. Service Planning Service Planning Considerations: Demonstration and Supplemental Services are time limited. Case Manager needs to consider the consumer's ability to maintain service animal or communication device such as a computer prior to authorizing service.

54. Service Planning If the case manager determines that it is not medically necessary for a consumer to receive a requested demonstration or supplemental service it is appropriate for the case manager to deny the request. Notice of denial of service and hearing rights must be sent to the consumer.

55. Service Planning Information regarding denials of HOME Choice Demonstration and Supplemental Services and hearing information related to such denials must be tracked and reported to ODJFS.

56. Questions?

57. Transition Coordination Responsibilities

58. Transition Coordination If a consumer appears to be eligible for the HOME Choice program, the case manager assists the consumer in choosing a Transition Coordination Provider. List of Transition Coordination Providers by county Consumer has free choice of provider List of TC provider’sList of TC provider’s

59. Transition Coordination Once a consumer chooses a Transition Coordination provider, the case manager completes the HOME Choice Demonstration and Supplemental Service Plan indicating the chosen Transition Coordination Provider.

60. Transition Coordination Transition Coordination is authorized on the HOME Choice Demonstration and Supplemental Service Plan by the case manager. Show planShow plan

61. Transition Coordination The ODJFS HCICCU: Contacts the identified TC provider and verifies their willingness/ability to provide transition coordination services to the consumer. Authorizes the payment of the first deliverable to the Transition Coordination provider. Notifies the case manager of the TC providers acceptance of referral and initiation of TC services.

62. Transition Coordination Transition Coordination Services help the consumer plan and arrange for the services and supports they will need while moving from an institution into the community. Transition Coordination begins during the pre-transition phase of HOME Choice participation and ends when a consumer moves into the community.

63. Transition Coordination Transition Coordination providers are required to provide up to 8 hours of housing navigation during the demonstration period if the consumer requires further assistance with housing navigation if due to their current living arrangement the consumer’s health and welfare is jeopardized.

64. Transition Coordination If housing navigation is still needed after the 8 hours is exhausted the transition coordinator must work with the case manager to secure prior authorization from ODJFS for additional service hours. Request for prior authorization must at a minimum include a detailed housing navigation budget.

65. Transition Coordination Transition Coordination Services include: Education and outreach about HOME Choice Assisting with the completion of the HOME Choice Workbook Participating in team meetings as scheduled by the case manager Participating in discharge planning from the institutional setting Arranging, securing or providing transportation for the purpose of visiting community resources

66. Transition Coordination Transition Coordination Services include: Assisting with linkage to employment options Assisting with the linkage of community resources as needed Assisting with linkage to managed care plan (if applicable) Benefits Coordination Housing Navigation Assisting in the use of community transition services (goods and services)

67. Transition Coordination Education and Outreach Transition Coordination Providers will provide education and outreach about HOME Choice to consumers, families, nursing facilities, etc. in their assigned service regions as needed.

68. Transition Coordination Education and Outreach ODJFS will provide written information such as brochures and fact sheets to be used as part of educational efforts.

69. Transition Coordination Assistance with Completion of Workbook All HOME Choice consumers will be given a HOME Choice Relocation Workbook. Assists consumers in determining their needs and desires for community living. Helps with planning steps a person needs to take before they move.

70. Transition Coordination Relocation Workbook contains questions regarding: Family & Friends Housing Medical Needs Personal Care Needs Transportation Personal Finances Employment Activities

71. Transition Coordination All HOME Choice consumers are encouraged to complete the workbook. Some consumers will need help from their transition coordinator in completing the workbook.

72. Transition Coordination If the Transition Coordinator has a different tool they would prefer to use to assist consumer with planning this is ok, the HOME Choice Relocation Workbook is not a requirement for participation in the program.

73. Transition Coordination The Transition Coordinator participates in team meetings as scheduled by the case manager. All HOME Choice participants will have an assigned case manager. The case manager will be from either a waiver entity (AAA, CBMR/DD or CareStar) or an ODJFS HOME Choice Care Coordinator for state plan only HOME Choice participants.

74. Case Manager Responsibilities During the consumer’s pre-transition phase the case manager: Schedules and leads team meetings for the purposes of discharge planning. Works to identify post discharge services and supports and develops a service plan. Coordinates activities and consumer’s discharge date with the transition coordinator. Show comparison chartShow comparison chart

75. Case Manager Responsibilities During the consumer’s pre-transition phase the case manager: Assists the consumer with securing service providers. Authorizes goods and services on the HOME Choice Demonstration and Supplemental Service Plan as needed. Submits the request for the Quality of Life Survey to the ODJFS HCICCU at least two weeks prior to consumer’s discharge.

76. Transition Coordination The Transition Coordinator participates in discharge planning from the institutional setting. Communicates with case manager and staff from the institution regarding consumer’s needs and desires post discharge.

77. Transition Coordination The Transition Coordinator: Arranges, secures or provides transportation for the purpose of visiting community resources. This could include: Helping the consumer obtain a bus pass Arranging cab service or public transportation Providing transportation directly to the consumer

78. Transition Coordination Transition Coordination Providers are not required to provide transportation directly to the consumer.

79. Transition Coordination The Transition Coordinator assists with linkage to employment options. Guide to employment contained in toolkit. Includes information on employment resources: RSC Disability Program Navigator MBIWD Senior Community Service Employment Program

80. Transition Coordination The Transition Coordinator assists with linkage to community resources as needed and as identified by the consumer.

81. Transition Coordination The Transition Coordinator assists with linkage to a Medicaid Managed Care Plan if needed. State Plan only HOME Choice consumers may be required to enroll in managed care once discharged from the facility.

82. Transition Coordination Managed Care The following groups of individuals are exempt from managed care enrollment: Individuals under the age of 21 Individuals who are dual eligible Individuals who are enrolled on a HCBS waiver Individuals who are eligible for Medicaid through a spend-down Individuals who are residents of nursing facilities.

83. Transition Coordination Managed Care All other individuals in the ABD category of Medicaid eligibility must enroll in a Medicaid Managed Care Plan. If you are unsure if a consumer must enroll in Managed Care contact the consumer’s worker at the CDJFS.

84. Transition Coordination Managed Care If managed care enrollment is required, the Transition Coordinator should assist the consumer in contacting the Medicaid Managed Care Enrollment Center. (1-800-605-3040) They can assist the consumer in choosing a managed care plan that best suites their needs.

85. Transition Coordination Managed Care If a consumer does not voluntarily choose a plan then a plan will be selected for them. Enrollment in managed care can occur as early as the beginning of the month following discharge from the facility.

86. Transition Coordination The Transition Coordinator assists with Benefits Coordination. Benefits Coordination includes but is not limited to: Identifying potential benefits Performing benefits analysis Assisting with the application of benefits Assisting with the development of a budget

87. Transition Coordination Benefits Coordination Benefits include, but are not limited to: Social Security VA Medicare Medicaid Food Stamps

88. Transition Coordination Benefits Coordination Resources in toolkit Benefit Bank Benefit Analysis through Work Incentives and Planning Assistance Program Benefits Navigator

89. Transition Coordination Qualified Residence In order to be enrolled in HOME Choice a consumer must move to a qualified residence. A home owned or leased by the consumer or family member An individually leased and lockable apartment rented by the consumer or family member A community-based residential setting with no more than four unrelated persons

90. Transition Coordination Qualified Residence A community-based residential setting with no more than four unrelated persons. Adult Foster Home (AAA’s) Adult Family Home (ODH) Assisted Living Facility (ODH) Non-ICF/MR Residential Facilities (ODMR/DD) Type 1 Residential Facilities (ODMH) Type 2 Residential Facilities (ODMH) Supported Living (ODMR/DD)

91. Transition Coordination Qualified Residence A community-based residential setting with no more than four unrelated persons. Group Home for Children Family Foster Home (ODJFS) Medically Fragile Foster Home (ODJFS) Pre-adoptive Infant Foster Home (ODJFS) Specialized Foster Home (ODJFS) Treatment Foster Home (ODJFS) HCBS Adult Foster Care (ODMR/DD)

92. Transition Coordination The Transition Coordinator assists with housing navigation. Housing Navigation includes: Assessing housing options that meet the consumer’s specific needs and preferences Helping the consumer identify available, affordable, sustainable housing Assisting with securing housing

93. Transition Coordination Housing Navigation includes: Verifying housing meets the definition of qualified residence Verifying licensure if applicable Verifying type of housing subsidy if applicable Assisting with the application process including helping to secure funds for security deposits and application fees Investigating and arranging rental subsidies

94. Transition Coordination Housing Navigation includes: Helping the consumer understand on going eligibility requirements to maintain housing Helping the consumer meet and negotiate with prospective landlords Assist with placement on housing waiting lists Helping the participant secure information needed to complete housing applications

95. Transition Coordination Housing Navigation includes: Assisting the consumer with overcoming housing barriers such as credit recovery and criminal convictions Assessing the need and developing a plan for home modifications Assisting with the connection of utilities Assisting the participant with and/or coordinating the actual physical move Helping the participant identify needed household items Helping find a roommate, if requested

96. Transition Coordination Housing Resources in Tool Kit Ohio’s Housing Locator Fair Housing How to verify licensure Affordable Housing Programs How to verify subsidies

97. Transition Coordination The ODJFS Housing Coordinator is available to help you with housing issues. Brock Robertson 614-752-3577 Brock.Robertson@jfs.ohio.gov

98. Transition Coordination The Transition Coordinator assists with the use of community transition services (goods and services) HOME Choice consumers may receive up to $2,000 for goods and services.

99. Transition Coordination Funds may be spent during the pre-transition period or during the demonstration period of HOME Choice participation. You do not have to spend all the money before a consumer moves!

100. Transition Coordination It is expected that community transition services (goods and services) will not be requested until housing is secured, unless a consumer needs access to the funds in order to secure housing.

101. Transition Coordination Community Transition Services (Goods & Services) Goods and services that will assist in a consumer’s successful transition into the community.

102. Transition Coordination Community Transition Services (Goods & Services) Includes but is not limited to: Security Deposits Essential Household Items Deposits for utilities Moving expenses

103. Transition Coordination Community Transition Services (Goods & Services) Does not include: Experimental or prohibited treatments Cost of room and board Uniforms and memberships Electronics used for entertainment purposes Cable/internet access Groceries

104. Transition Coordination Community Transition Services (Goods & Services) The Transition Coordinator, as directed by the consumer, assists the consumer in determining the most effective use of the transition funds.

105. Transition Coordination Community Transition Services (Goods & Services) During the pre-transition phase of HOME Choice, the transition coordinator will work with the consumer on completing the Estimated Use of Goods and Services form. The form is an estimate only!

106. Transition Coordination Community Transition Services (Goods & Services) The form contains a framework of acceptable uses of the transition funds. Other requests not identified as a category on form require ODJFS approval. The Transition Coordinator should contact the ODJFS HCICCU to discuss these request prior to submitting the form to the case manager.

107. Transition Coordination Community Transition Services (Goods & Services) The ODJFS HCICCU will consider other requests on a case by case basis.

108. Transition Coordination Community Transition Services (Goods & Services) Upon completion of the Estimated Use of Goods and Services, the form is sent to the case manager. The case manager authorizes Community Transition Services (Goods & Services) on the HOME Choice Demonstration and Supplemental Services Plan.

109. Transition Coordination Community Transition Services (Goods & Services) The case manager sends the HOME Choice Demonstration and Supplemental Services Plan and a copy of the Estimated Use of Goods and Services form to the ODJFS HCICCU. The ODJFS HCICUU reviews the information and gives final authorization for the release of funds.

110. Transition Coordination Community Transition Services (Goods & Services) The ODJFS HCICUU sends the approved HOME Choice Demonstration and Supplemental Service Plan to the Financial Management Service (FMS). The FMS establishes an account for the consumer from which the transition coordinator can request funds.

111. Transition Coordination Community Transition Services (Goods & Services) The Transition Coordinator tracks the actual use of funds on the HOME Choice Goods & Services Usage Log. If a consumer changes their mind on how they want to use their funds, a new estimated use of goods and services funds form is not required. Unless consumer is requesting something in the “other category”.

112. Transition Coordination Community Transition Services (Goods & Services) Once purchases are made all receipts are turned in to the FMS. The Transition Coordinator must track to insure consumer does not exceed $2,000.

113. Transition Coordination Community Transition Services (Goods & Services) If in doubt, call the ODJFS HCICUU!

114. Questions?

115. Deliverables Transition Coordination Providers are paid $5,000 per consumer. Paid in 3 deliverables $3,000-upon acceptance of a referral $1,000-upon securing qualified housing $1,000-upon consumer’s discharge from facility

116. Deliverables 1st Deliverable-$3,000 Paid upon accepting a new referral The ODJFS HCICCU will notify you via phone when you have been selected by a consumer. If you accept referral, the HCICUU will communicate directly with the FMS to pay the first deliverable. You are not required to submit anything to the FMS or to the HCICCU in order to receive payment.

117. Deliverables 2nd Deliverable-$1,000 Paid upon finding qualified housing When housing is secured, the Transition Coordinator completes the Transition Coordination Qualified Residence Statement. The Transition Coordinator must include verification of the secured housing such as a lease, case note documenting conversation with family, etc.

118. Deliverables 2nd Deliverable-$1,000 Paid upon finding qualified housing The transition coordinator completes the Transition Coordination Services Statement. The transition coordinator submits the Transition Coordination Services Statement, the Transition Coordination Qualified Residence Statement and required supporting documentation to the ODJFS HCICCU. Show formShow form

119. Deliverables 2nd Deliverable-$1,000 Paid upon finding qualified housing The ODJFS HCICCU reviews information and approves payment of deliverable. The ODJFS HCICCU sends approval of deliverable to the FMS who sends the transition coordination provider payment.

120. Deliverables 2nd Deliverable-$1,000 Paid upon finding qualified housing Information contained in Qualified Residence Statement required by CMS for reporting purposes.

121. Deliverables 3rd Deliverable-$1,000 Paid upon consumer’s relocation to the community When a consumer moves, the transition coordinator completes the Summary of Transition Coordination Activities form.

122. Deliverables 3rd Deliverable-$1,000 Paid upon consumer’s relocation to the community Form contains required data elements that must be reported to CMS. Estimate time spent on activities as best as you can. Time Study not needed. Show formShow form

123. Deliverables 3rd Deliverable-$1,000 Paid upon consumer’s relocation to the community The transition coordinator completes the Transition Coordination Services Statement. The transition coordinator submits the Transition Coordination Services Statement and the Summary of Transition Coordination Activities form to the ODJFS HCICCU.

124. Deliverables 3rd-$1,000 Paid upon consumer’s relocation to the community The ODJFS HCICCU reviews information and approves payment of deliverable. The ODJFS HCICCU sends approval of deliverable to the FMS who sends the transition coordination provider payment.

125. Deliverables If a consumer disenrolls from program prior to relocating to the community, but after a deliverable payment to the transition coordination provider has been made, the deliverable payments do not have to be returned as long as the transition coordinator submits the Summary of Transition Coordination Activities form to the ODJFS HCICCU.

126. Questions?

127. Documentation Required documentation Consumer cover sheet that includes basic demographic information. Case notes documenting all contacts with or on behalf of the consumer. Can be written or electronic Must be signed and dated by transition coordinator exampleexample

128. Documentation Required documentation Releases of Info on HIPPA complaint forms ODJFS approved forms for tracking of goods and services Copies of the HOME Choice Demonstration and Supplemental Service Plans Show exampleShow example

129. Service Monitoring Transition Coordination Providers must: Review each consumer’s case record to ensure all required documentation is present. Have monthly face-to-face staffing meetings with each transition coordinator to discuss the consumer’s progress. Maintain documentation of service monitoring. Documentation of such must be included in the consumer’s case record.

130. Incident Reporting During the pre-transition period incidents involving consumers should be reported: To the nursing facility for nursing facility residents To the ICF/MR and CBMR/DD for residents of an ICF/MR

131. Incident Reporting If a transition coordinator is working with a consumer during the demonstration period incidents should be reported to: CBMR/DD for consumer’s on ODMR/DD administered waivers AAA’s for consumer’s enrolled on PASSPORT CareStar for consumer’s enrolled on ODJFS-administered waiver ODJFS for State Plan Only HOME Choice consumers Sample incident reports can be provided if needed-what must be reported in tool kitSample incident reports can be provided if needed-what must be reported in tool kit

132. Tool Box Includes: Transition Coordinator Step-By-Step Copies of all required forms OAC Rules Transition Coordination Maps and Contact Info ODJFS Contact Info Housing Information Employment Guide Relocation Workbook Incident Reporting Information

133. Questions?

134. Thanks!