Transitional Living 525-05-30-70

(Revised 7/1/15 ML #3460)

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Purpose

A program which provides training for the client to live with greater independence in the home.

Service Eligibility, Criteria for

The individual receiving Transitional Living Services will meet the following criteria:

1. Must be eligible for the Medicaid Waiver for Home and Community Services;
2. Service/care is delivered in the recipient’s private family dwelling (house or apartment);
3. Individual must benefit by receiving Transitional Care Services and is cost-effective and necessary to avoid institutionalization;
4. Require supervision, training, or assistance  with self-care, communication skills, socialization, sensory/motor development, reduction/elimination of maladaptive behavior, community living and mobility;
5. Disabled as determined by Social Security Disability criteria; and
6. Recipient is capable of directing own care as determined by the interdisciplinary ICP team, or have a (legally) responsible party to act in the recipient’s behalf.
7. Pre-approval from the Department of Human Services is required before this service can be authorized.

Service Tasks

Tasks that can be authorized are bathing, communication, community integration, dress/undress, eye care, feeding/eating, hair care/shaving, housework, incontinence, laundry, meal preparation, medication assistance, money management, nail (finger) care, shopping, skin care, social appropriateness, teeth/mouth care, toileting, transferring/turning/positioning. Escort to accompany individuals while they are being transported to/from work or school, to facilitate socialization, or to participate in recreational activities is allowed.

The global endorsements of cognitive/ supervision, exercises, Hoyer lift/mechanized bath chairs, indwelling catheter, medical gases, prosthesis/orthotics, suppository/bowel program, ted socks, temp/BP/pulse/ respiration rate and the client specific endorsements of apnea monitor, Jobst stockings/ostomy care, postural/bronchial drainage and Ric bed care may also be authorized.

Tasks must be identified on the Authorization to Provide Waiver Service SFN 404.

Service Combinations

1. Non-Medical Transportation Driver w/Vehicle may be combined with Transitional Care Service.
2. Non-Medical Transportation Escort Service is Transitional Care and therefore would not be authorized.
3. Respite care may be combined with Transitional Care Service.
4. Adult Day Care may be combined with transitional care.
5. Homemaker, adult foster care, adult residential care and family personal care cannot be authorized with transitional care services.

Individual Program Plans

Once an individual begins Transitional Care, an Individual Program Plan must be completed by the interdisciplinary team (to at least include the service provider, the individual and/or their legal representative) and the case manager.  

This plan must be completed within 30 days of the beginning effective date of the services. The Plan must include how the provider will meet the needs of the client, AND the plan for the promotion of the client’s independence in ADLs and IADLs, social, behavioral, and adaptive skills.

The Plan must also identify the goal or goals of the individual and how the goals will be accomplished. This Plan will be subject to review by the HCBS Case Manager during the initial Plan implementation period and every six months thereafter. At the team meeting, the team will review the goals and progress, and strategies for accomplishing the plan goal or goals.

Service is provided until the interdisciplinary team determines this service is no longer appropriate.