(Revised 8/1/07 ML #3106)
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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:
Must be eligible for the Medicaid Waiver for Home and Community Services;
Service/care is delivered in the recipient’s private family dwelling (house or apartment);
Individual must benefit by receiving Transitional Care Services and is cost-effective and necessary to avoid institutionalization;
Require supervision, training, or assistance with self-care, communication skills, socialization, sensory/motor development, reduction/elimination of maladaptive behavior, community living and mobility;
Disabled as determined by Social Security Disability criteria; and
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.
Service Tasks
Tasks that can be authorized are identified on the SFN 1012, Monthly Rate Worksheet, and the SFN 1699, Authorization to Provide Service.
Service Combinations
Non-Medical Transportation Driver w/Vehicle may be combined with Transitional Care Service.
Non-Medical Transportation Escort Service is included in the Transitional Care Daily rate and therefore would not be authorized.
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.