Get Rhode Island Dhs Transition Nursing Home Form

The Rhode Island Dhs Transition Nursing Home Form is designed to facilitate the transition of individuals from nursing homes back to their communities. This guide provides a clear and supportive approach to help users fill out the form online effectively.

Follow the steps to complete the Rhode Island Dhs Transition Nursing Home Form.

1. Use the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Fill in today’s date at the top of the form to indicate when you are completing it.
3. Provide the name and phone number of the nursing home in the designated fields. This identifies where the individual is currently residing.
4. Enter your name as the person submitting the form. This ensures that you can be contacted for any follow-up.
5. Indicate if the referral is in response to MDS Section Q by checking the appropriate box.
6. Fill in the individual's name, date of birth, and primary language to ensure accurate identification and communication.
7. Select the reason for the referral by checking either 'Information Only' or 'Interest in Transition', based on your intent.
8. Provide the individual's Social Security Number in the indicated field.
9. Indicate whether an interpreter is needed by checking 'Yes' or 'No'.
10. Answer the questions regarding chronic homelessness and veteran status by checking the appropriate boxes.
11. Enter the name of the individual's health insurer and secondary insurer if applicable.
12. Indicate whether the primary payer is PACE and if the individual has Long Term Care Medicaid.
13. If the individual does not have Long Term Care Medicaid, indicate whether an application has been submitted and provide the relevant dates and locations.
14. Discuss if the individual anticipates applying for MA in the future and provide a diagnosis as well as BIMS score.
15. Select any care planning needs the individual may have by checking the relevant boxes.
16. Indicate if the individual requires 24-hour supervision by checking 'Yes' or 'No'.
17. Answer whether there is documentation supporting that a transition to the community would not be appropriate.
18. Provide any additional comments that may be relevant for the referral process.
19. Indicate if the individual has a legal guardian or power of attorney and provide their contact information if applicable.
20. Document if the family or guardian has been notified of the referral.
21. Fill in the anticipated discharge date, nursing home discharge planner's name, and admission date along with the reason for admission.
22. Indicate where the individual was admitted from and any recent hospitalizations, also provide agency names if services were received in the community prior.
23. Discuss whether the individual has a case worker and relevant details.
24. Explain the nature of the individual's family support system.
25. Complete the information regarding future living arrangements and the community address if known.
26. Provide contact information for a primary contact person and any previous referrals to the nursing home team.
27. Once all sections are complete, review the form for accuracy and save changes. You may then download, print, or share the form as needed.

Complete and submit the Rhode Island Dhs Transition Nursing Home Form online to ensure a smooth transition process.