Connections to Community Living
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.
Links to helpful resources:
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Last Revised: April 17, 2013 |
