MFP Transition Plan - NC

North Carolina Money Follows the Person Transition PlanTransition Planning GroupParticipant’s Name andContact InformationCOUNTY INFORMATIONRepresentative’s (ifapplicable) Name andContact Information andRelationshipOther Friends/Family:Transition CoordinatorContact Information:Transition Coordinator’sName and ContactInformation:Facility Name and ContactPerson’s InformationOthers:Medicaid County:County Currently ResidingIn:County MovingTo:Will Medicaid beTransferred?TRANSITION INFORMATIONDate Initial TransitionPlanning Meeting Held:Date Final TransitionPlanning Held:Estimated Transition Date:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 1 of 15

WHY THIS MATTERS TO MEWhat am I looking forward to about transitioning into my own home/community?My History: Why I Came to the Facility in the First Place:My Future: What I’m Looking Forward to About Being in my Home and Community:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 2 of 15

WHERE I WILL LIVEI do/do not have a home (own orfamily’s) to return to (circle one).If not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).If no, my housing needs related to: affordability accessibility rent utility deposits neededList Here:Basic household safety needs (fireextinguisher, smoke detectors,etc.):List here:Other:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 3 of 15

MY MEDICAL SUPPORTSMy Community-BasedMedical NeedsIf not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.)I will enroll in Community Care of North Carolina (please circle one): Yes or NoMy doctor will be:Needed Specialists:My dentist will be:My pharmacist will be:OtherStrategy for ensuringcontinuity of care betweenfacility and communitybased medical services.(i.e. Ensuring sufficientmedication isavailable./prescriptions arein place, etc.)Type of assistance neededwith medications.NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 4 of 15

MY ADAPTIVE EQUIPMENT NEEDSI do/do not haveadaptive equipmentneeds. (circle one)If not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.)Mobility (wheelchair,walker, etc.)Home modificationsIndependence AidsUse of In-homemonitoring(Simply Home, RestAssured, Life Line)Adaptive Supplies(modified dishes, gaitbelts, etc.)NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 5 of 15

MY MENTAL HEALTH/BEHAVIORAL SUPPORT NEEDSI do/do not havemental health,substanceaddiction orbehavioralsupport needs(circle one).Is there a currentbehavior supportplan in place ifneeded?Linked with NCStart (if applicable)Linked withcommunity-basedpsychiatrist (ifneeded)Linked withcommunity-basedpsychologist (ifneeded)Special stafftraining (asneeded)Linked with theappropriatesubstanceaddiction supportservices if needed.If not secured, what ispreliminary plan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.)Amount of support confirmed to be provided:Amount of support confirmed to be provided:Amount of support confirmed to be provided:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 6 of 15

WHAT I NEED TO FEEL SAFE IN MY HOME and COMMUNITYSafetyIf not secured, what is preliminary plan fordeveloping?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).What I Need to FeelSafeHow I will get outin a fire in themiddle of the nightNC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 7 of 15

MY MONEYMy IncomeIf not secured, what ispreliminary plan fordeveloping?Who will take the lead?Does it need to transfer?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).Where Will I Bank When I Move?Supplemental Security Income:Monthly Amount:Social Security Disability IncomeMonthly AmountOther Income?Monthly Amount:Will I have a Medicaid deductible?Am I Eligible for Food Stamps?Am I Eligible for Other Support Services?What personal documents do I need tosecure?State issued IDSocial Security CardBirth CertificateOtherPlan for Ensuring Benefits Transfer fromFacilityNC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 8 of 15

HOW I’ll GET AROUND IN MY COMMUNITYIf not secured, what is preliminary plan fordeveloping?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).Will I have access topublic transportation?Do I need accessibletransportation?How will I get tocommunity-basedactivities andappointments?NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 9 of 15

BEING INVOLVED IN MY COMMUNITYIf not secured, what ispreliminary plan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).I do/do not (circle one) want to workfor pay.I do/do not want (circle one) toexplore continuing educationopportunities.How will I spend my day in a way thatprovides the support, social opportunityand structure I want and need?I do/do not (circle one) have friendsand family where I’m moving to.If no, what are the plans forsupporting me to build community?I do/do not (circle one) want to beconnected to a peer mentor.I do/do not want to be connected withother people in my area who aresupporters of MFP and of buildinginclusive communities.These are the people I would like to remain in contact with once I leave the facility.These are some of the people in my community, I’d like to reconnect with once I return home:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 10 of 15

MY SCHOOLI am/am not (circle one)school aged.If not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).Name and contactinformation for the schoolI will be attending.The particularsupports, devices, ortherapies that I need toattend school are:Has there been an IEPmeeting scheduled? If so,what is date?NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 11 of 15

MY STAFFIf not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).I would like to helpselect the staff whoare working with me.Yes NoHow my staff will betrained:What are theimportant things thatneed to be included inmy staff’s training?Will my staff visit/trainwith me before Itransition?NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 12 of 15

MY FAMILY/SUPPORT NETWORKIf not secured, what is preliminaryplan for developing?Who will take the lead?Finalized Plan and Contact Information(i.e. address of apartment, doctor’s name, etc.).How will my family orfriends participate inmy supports?If I am going home tomy family,we do/ do not (circleone) want to try ahomestay beforetransitioning.Do these familymembers wantinformation aboutcaregiver supportoptions?Do these familymembers/friendsunderstand respiteoptions available?Other family-specificconsiderations.NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 13 of 15

OUR BACK UP PLANSIF .WE WILLIf natural supportsbecome worn out .If the staff don’t showup .If we realize we needmore paid services:If a providerdiscontinues services:If there is a medicalemergency:Other Person-SpecificContingency Plans:If NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 14 of 15

THE FINAL PAGEOther “To Dos” Not Otherwise Listed:Staying In TouchHow often do we want to connect (by phone/email/conference call)When do we need to meet in person again?Will we be accessing MFP’s Transition Year Stability Resources?List Needs Here:Have we contacted Project for latest TYSR Protocol?Have we submitted requests?Date Preliminary Plan Submitted to MFP:Date Final Plan Submitted to MFP:Transition Coordinator’s Signature on Final Plan Submitted to MFP:NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011,Final Draft Developed September, 2011Page 15 of 15

NC MFP Transition Planning Tool, Developed September,2010; Revised October, 2010; Revised March, 2011, Final Draft Developed September, 2011 Page 1 of 15 North Carolina Money Follows the Person Transition Plan COUNTY INFORMATION Medicaid County:_ C