New Jersey Department of Human Services

Division of Aging Services

TRANSITION PLAN

Consumer Name

Date of NF Admission

Dates of Previous NF Admissions and Discharges

Consumer’s Goals:
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Cultural Concepts/Personal Preferences to be Considered:
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Desired Outcomes – Maintenance, Independence, Rehabilitation, Prevention or Other:
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Consumer Strengths/Desires/Responsibilities to Achieve Goals:
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3.

Consumer’s Support System to Achieve Goals:
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Consumer Name

Services and Supports Needed for Transition:

Service Needed	Frequency	Number of Units	Cost per Unit	Total Cost

Justification for Waiver Service Costs that exceed $2,841 per month:

Consumer Risk Factors:

Factors that, if not addressed, might pose a high threat to an individual’s health and welfare. These include: (a) health risk (medical conditions that require continuing care and treatment); (b) behavioral risk (behaviors or conditions that might cause harm to the person or others); and, (c) personal safety risk (e.g., safe evacuation).
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Backup Plan(s) to Address Risk Factors:

Provision for alternative arrangements for the delivery of services that are critical to participant well being in the event that the provider responsible for furnishing the services fails to or is unable to deliver them.
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Transition Team Members, Phone Number and Responsibilities:

Name	Phone number	Responsibilities

Consumer Name

Consumer Choices
Yes	No	N/A
1.	I have been advised and understand that I may choose to remain in the nursing facility or move to a community setting to receive home and community-based services.
2.	I voluntarily choose to return to the community to receive home and community-based services.
3.	I have been advised about the Global Options (GO) Program and services.
4.	I voluntarily agree to participate in the GO Program.
5.	I have been advised of the potential risk factors identified in this Transition Plan if I leave the nursing facility to return to a community setting with services through the GO Program.
6.	I understand and accept the potential risk factors if I leave the nursing facility to return to a community setting.
7.	I was a member of the Transition Team that planned my discharge from the Nursing facility to the community.
8.	I helped develop this Transition Plan and the Plan of Care.
9.	I had the freedom to choose my services under the GO Program.
10.	I had the freedom to choose the providers of my services based on available providers. I am aware that I may not receive the providers I have chosen.
11.	I agree with this Transition Plan and the Plan of Care.
12.	I was advised that the amount, frequency, and continuation of services depend upon the availability of state and federal funds.
13.	I am aware that I may have a cost share for Assisted Living/Adult Family Care.

Anticipated Date of Discharge

Consumer	Date
Witness	Date
Witness	Date
Witness	Date

Actual Date of Discharge

Destination

TRANSITION PLAN, Continued

LTC-31

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

LTC-31, TRANSITION PLAN

LTC-31, Aging Services, transition, nursing facility, LTC, ACS,

Windows User

2014-12-04

human services