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Wisconsin Department of Health Services

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Information for Family Care & IRIS Staff

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Information for Nursing Home Staff

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Information for Nursing Home Staff

Nursing home employees, especially social workers, are an integral component of a successful move to the community. The Social Worker participates in the development of an interdisciplinary treatment plan including the assessment of each resident. The plan includes the resident’s potential to return to the community. The Social Worker has a knowledge base of community resources which are available to the long-term-care resident as well as those residents with discharge potential. The Social Worker is an advocate who promotes self-advocacy for residents and an increased awareness of issues that impact on the quality of life of nursing home residents. The Social Worker is involved with the development of discharge planning to reflect the resident’s potential to return to the community including supports needed.

Consumer advocates, states, and CMS are advancing nursing home transition programs to help older adults and people with disabilities leave nursing homes and return to their homes and communities. An essential component of nursing home transition efforts is assertive identification of the nursing home residents who prefer a home or community-based setting rather than the nursing home. One way to help identify individuals who want to transition is through the Long Term Care Minimum Data Set (MDS); especially Section Q dealing with discharge potential and overall status of the resident.

Some counties have been identified as areas with large numbers of Medicaid funded nursing home residents (PDF 46 KB). In those areas the state will assign Community Living Specialists (CLS) to assist the ADRC with outreach and information to nursing home residents and nursing homes staff. Their primary responsibilities include outreach to residents; outreach to nursing home staff; problem solve/overcome barriers and coordinate relocation and work with partners to ensure smooth/timely relocation.

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Last Revised: April 17, 2013