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Nursing Home Person Centered Transition to Community Living Project

The Nursing Home Person Centered Transition to Community Living (NHPCT) project is designed to facilitate the transition of residents from nursing facilities to community living.

The goal of the NHPCT Project is to strengthen the education and outreach provided to nursing facilities that will be making referrals to the local contact agencies (LCAs). In New Hampshire, ServiceLink is identified as the local contact agency for this project.

When an individual expresses interest in transitioning from a nursing facility back into the community, nursing facilities will now be required to send referrals to the designated LCA. The LCA will be responsible for contacting residents, discussing options, and assisting interested residents to return to the community.

On October 1, 2010, nursing facilities across the country began using a new version of the Minimum Data Set, called MDS 3.0. The Minimum Data Set (MDS) is a comprehensive assessment performed on residents of nursing facilities certified to participate in Medicare or Medicaid. All residents admitted to a nursing facility, regardless of income or resources, receive this assessment upon admission and periodically thereafter. The updated version includes a revised section Q designed to identify residents who may be interested in moving back to the community. This information will be used to identify potential individuals for transition. In 2011 the ServiceLink Aging and Disability Resource Center Program (SLRC) was designated as the LCA (first point of contact) for Section Q referrals.

To assure that Section Q was effectively implemented, a group of community stakeholders was formed. The group included representatives from nursing facilities, community support providers, Granite State Independent Living, the Office of the Long-Term Care Ombudsman, the NH ServiceLink Network, and the NH Department of Health and Human Services (specifically the Bureau of Elderly and Adult Services and the Bureau of Health Facilities). Over the course of several months, the stakeholders united, shared their best practices, expertise and perspectives to collectively develop a standardized referral process for use by NH’s nursing homes.

The referral process was successfully piloted with eight nursing facilities in six New Hampshire communities. Lessons learned through the piloting process afforded the stakeholders group the opportunity to identify best practices, revise processes in an effort to sustain a seamless referral process for nursing facility residents to learn about and/or transition out of facilities and back into community living. Between June 2012 and November 2012, statewide training sessions were offered to nursing facilities on the MDS 3.0 Section Q Referral Process and Toolkit, along with an introduction to the person-centered planning process. Trained participants included MDS coordinators, discharge planners and nursing facility social workers. SRLC staff and Granite State Independent Living staff also participated.

The MDS 3.0 Section Q Referral Process Toolkit Adobe Acrobat Reader Symbol includes the Section Q Reference Manual, forms, fact sheets and other educational materials. It is designed to provide nursing facilities with the resources needed to assist residents who indicate an interest in returning to the community.

New Hampshire's MDS 3.0 Section Q Training module and resource (national and local) website provides detailed information about MDS 3.0 Section Q and the Referral Process.

Adobe Acrobat Reader Symbol Adobe Acrobat Reader format. You can download a free reader from Adobe.

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New Hampshire Department of Health and Human Services
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