1. Delaware Passport to Independence From the Division of Services for the Aging and Adults with Physical Disabilities (DSAAPD) Prepared by Jewish Family Services of DE (Contractor for Outreach/Training) Approved for use by Delaware Passport to Independence

2. Pilot Project To identify residents of nursing homes who may want to move to a new home To interview and assess residents for possible community living To explore if it’s feasible for some residents to transition To create an Individualized Service Plan for those choosing to be considered

3. CHOICES for long-term care! Skilled Nursing Assisted Living Community Living, alone or with others

4. Training and Outreach Project Educating nursing home staff Educating community agency workers Educating hospital discharge planners Educating doctors, nurses and social workers

5. Training and Outreach Project Reaching out to nursing home residents Contacting families Finding community support services Informing the public of the Passport Project and its options

6. Project Oversight DSAAPD Community Partnerships Statewide representation Consumer participation Mutual decision-making

7. Goals To have personal contact with EVERY nursing home in the State of Delaware within the year To gain cooperation in identifying candidates for transition to community housing To accept referrals and application for assessment of feasibility for transition To offer assessment to all who apply

8. Assessment and Evaluation Available for every nursing home resident who requests and applies for assessment Performed by qualified professionals Thorough analysis of abilities to function in a community housing setting Consultation to evaluate medical, physical, and emotional readiness for independence Participation by residents and families

9. Who is eligible?(for assessment) Nursing home residents supported through Medicaid Residents with physical limitations Referred to the DPI (Delaware Passport to Independence) program Applied for consideration and assessment

10. Determination Process Initial interview Complete Assessment Thorough evaluation of Assessment findings Discussion of feasibility for resident and family to make decisions

11. Transition Process... Definition: PROCESS = action over the course of TIME ! Immediate transition Complicated transition Incremental transition

12. Transition Process... Resident and family informed about feasibility Consumers and family devise an Individualized Service Plan (ISP) with Assessment Team participation With consumers, Assessment Team prepares a Community Orientation Plan and locates local support services Consumers and Assessment Team monitor transition process and progress Consumers receive Case Managers who will continue to guide and advocate

13. Consumer DECISIONS Stay in place Opportunities for employment, education, socializing, traveling are available for facility residents! Relocate Explore the feasibility of transition utilizing this Project.

14. Consumer DECISIONS For some, the security and protection of facility living is preferred For others, it feels confining and limiting Living alone may feel frightening or exciting

15. Getting started Talk with the staff where you live now Talk to your doctor and therapists Talk with friends and relatives Ask yourself hard questions about where and how I want to live Ask yourself how much time and energy do I have to care for myself

16. For Information or Questions DSAAPD Delaware Passport to Independence Victor Orija (Program Manager) 302-255-9377 (Phone) 1-800-223-9074 (Phone) victor.orija@state.de.us (E-mail)