It is important to establish and maintain a transition planning process with the home before, during and after the move. The following checklist provides a guide to transition planning meetings with the provider of the alternative home whether it is a long term care (LTC) or retirement home or supported seniors’ apartment.
Get Ready
- Identify the participants and ensure they are available to support the transition planning process; participants may include: Supervisor and/or Manager, Primary Support Worker– Residential and Day Program, Family members, Community Care Access Centre (CCAC) Coordinator, other involved services, Director of Care from the LTC home and other appropriate individuals from the home or long term care facility.
- Set a schedule for meetings in advance, if possible, so everyone can reserve these dates in their respective schedules.
Set the Agenda
The points of discussion for a transition meeting or series of meetings will vary with the needs of the individual and the paid and unpaid caregivers involved in the process. The checklist below provides a picture of many possible items that should be discussed at some point during the transition planning meetings.
Background Information on the Person
- History of the individual, the factors that led to the decision to seek alternative residential or LTC placement, his/her current needs, strengths and wishes.
- History of the involvement of the family – some families have been very involved in the support of their son or daughter throughout their life, others have not; in the case of the Public Guardian Trustee (PGT) as the decision-maker, ensure early involvement of the PGT staff and identify the nature of the relationship of Developmental Service agency staff to the client in the absence of family.
The Individual’s Current Living and Support Situation
- Living Independently
- Living at home with his/her family
- Supportive Housing
- Supported by a Developmental Service Agency (DS agency)
Current Provider Name (if applicable)
Address
Telephone number:
E-mail address:
Key contacts at current providing agency:
Supervisor and/or Manager & Contact Number:
Primary Support Worker & Contact Number:
Other supports the person is receiving:
CCAC—supports provided via CCAC
Day Program – (provider name)
Therapeutic
Medical
The Individual’s Support Needs
- Review the individualized supports needed for this individual and how these will be put in place during transition and after the move to the new residential placement.
- Determine how existing social relationships will be maintained.
- Confirm staffing during and after transition in the LTC home – identify the role and responsibilities of the staff from the DS agency when they are supporting the individual living in the LTC home.
- Confirm the plans of the DS agency for long-term contact with the client – e.g. ongoing visits by the staff and the individual’s friends.
- Supports that need to be put in place while the individual is waiting to move (via the CCAC or other sources).
Orientation
- Arrange for pre-move visits to the home by the family, individual and DS agency staff.
- Arrange pre-move visits by the home staff to the group home.
- Schedule pre-move visits by the individual. This may be gradual beginning with day visits and extending to overnight.
- In the case of a move to a long term care home investigate possible use of respite services for overnight stays.
Cross Sector Information Exchange
- How the DS agency staff will train and provide information about the individual to the staff at the LTC home (this may need to be provided in different formats and on several occasions for different shifts of staff – this may also be needed to be repeated when necessary).
- Provide other information that may be needed to the LTC home such as psychological and medical reports.
- Consider how financial management has occurred in the past and how it may have to be adapted to the current living situation. (in many cases, the DS agency has managed the individual’s finances; some families may wish the LTC home to take over this responsibility)
Moving In
- Identify what the individual should bring to the new home and what items need to be purchased ahead of time.
- Schedule the time and date of the move.
- Arrange for support to the individual during the move both at the old and new locations.
Developing Partnerships Between the DS Service Provider and Family
- Visits, activities, outings.
- Participation in case conferences and other meetings.
- Ongoing communication processes / protocols among the family, DS agency and residential provider.
- Involvement in decision-making regarding the support plan.
- Participation in the resolution of issues and challenges – being part of the problem-solving team – offering possible resources.
- Supporting family in finding out about and joining the family council or other participatory processes within the residential setting.
Developing Partnerships With the Residential Provider
- Establish and maintain ongoing communication with the family and the new residential provider.
- Inform and involve family and DS agency in significant events such as: case conferences, plan of care meetings, decisions regarding the support/care of the individual.
- Orient DS agency staff and family to the home.
- If DS agency staff are working in the home during transition or ongoing – orient and train staff about the routine, activities and any necessary policies and procedures.
Identifying Key Contacts in the New Home and With Other Providers Involved in the Support Plan
It is important to keep in close touch with other players in the person’s transition plan and ongoing support. Keeping a contact list of all the players and sharing it with everyone involved can facilitate smooth communication.
Residential Provider
Administrator:
Name
Contact Numbers:
E-mail:
Director of Care:
Name
Contact Numbers:
E-mail:
Other: ______________
Name
Contact Numbers:
E-mail:
Developmental Service Agency
Executive Director:
Name
Contact Numbers:
E-mail:
Program Director:
Name
Contact Numbers:
E-mail:
Other: ______________
Name
Contact Numbers:
E-mail:
Family
Parents:
Name:
Contact Numbers:
E-mail:
Siblings:
Name
Contact Numbers:
E-mail:
Other: _________________
Name
Contact Numbers:
E-mail:
Sourced from “Transition Guide For Caregivers”, The Ontario Partnership on Aging and Developmental Disabilities http://www.opadd.on.ca