<p>Ohio Department of Medicaid Interview Date: o Phone Contact w/Resident In-Person Visit With Resident In-Person Visit did not occur (complete next section only) HOME Choice COMMUNITY LIVING PLAN ADDENDUM</p><p>Last Name of Resident: Date of Birth: First Name of Resident: Age of Resident: Name of CLS Agency: Name of CLS Contact: Date of Admission: Name of Nursing Facility: </p><p>Date Referral Received: Date of Initial Phone Contact with the Resident: </p><p>If In-Person Meeting did not occur, please select one main reason why: ☐Trouble contacting NF/ resident ☐Resident requested to reschedule ☐ Guardian refusal ☐Resident refused visit ☐In-person visit not needed due to recent LTCCDate of LTCC (MM/DD/YYY): ☐Connected to Waiver Services ☐Resident wishes to remain in the nursing facility ☐End stage hospice ☐ Duplicate ☐ Discharged ☐Hospitalized ☐Other (please describe): </p><p>Section A: Individuals’ Meeting Summary- based on the individual’s responses (or family/guardian) Please complete Section A to document the In-Person Visit or Phone Contact with resident Needs and Preferences Referrals and Resources</p><p>1 | P a g e Revision Date 04/10/2015 Resident Needs Assistance With (check all that The CLS checked the following on the resident’s behalf apply- at least one resource must be checked) and provided a list of resources (check all that apply- at ☐ Finding housing least one resource must be checked): ☐ Finding assisted living ☐ Ohio Benefit Bank ☐ Finding group homes ACF/ AFH ☐ Ohio Housing Locator ☐ Finding supportive housing ☐ Benefits Checkup ☐ Assuring accessible housing ☐ Long Term Care Consumer Guide ☐ Locating resources to pay for housing ☐ Long Term Care Resource Advisor ☐ Locating resources to maintain housing (e.g. ☐ HOME Choice Relocation Workbook housekeeping) ☐ Other ______☐ Finding service and support providers ☐ Other ______☐ Finding programs that provide personal care Service Providers ☐ Finding programs that provide nursing care ☐ Primary Care Doctor ☐ Locating community food pantries ☐ Home Health (nursing and/or aide services) ☐ Finding a primary care physician in the community ☐ Therapies ☐ Finding a pharmacy in the community ☐ Nursing (Medication Management) ☐ Connecting with physical, occupational, and/or ☐ Pharmacy speech therapies ☐ Mental Health Treatment ☐ Connecting to mental health resources ☐ Alcohol and Other Drug Recovery ☐ Connecting to community alcohol and drug ☐ Transportation resources ☐ Durable Medicaid Equipment ☐ Setting up transportation in the community ☐ Meals ☐ Managing monthly finances (e.g. paying bills) ☐ OACBHA ☐ Getting SSI/ SSDI ☐ Other ______☐ Legal assistance Housing ☐ Credit recovery ☐ Public Housing ☐ Setting up public benefits such as food stamps, ☐ Subsidized Housing cash assistance, etc. ☐ Supportive Housing ☐ Accessing local community supports such as home ☐ Residential Housing (e.g. Adult Care Facility) energy assistance, cell phone support, etc. ☐ Apartment/Home Listings ☐ Finding employment ☐ Rental Assistance Programs ☐ Purchasing items (e.g. furniture, kitchen items) for ☐ Other______a community setting Employment Services ☐Obtaining durable medical equipment ☐RSC/ Opportunities for Ohioans with Disabilities ☐Veterans benefits coordination ☐Disability Program Navigator ☐Other ☐Medicaid Buy-In for Workers with Disabilities ☐Senior Community Service Employment Program ☐Employment and Training One-Stop System Protection from Harm ☐LTC Ombudsman ☐ Department of Health ☐Adult Protective Services Other ☐SSI/SSDI Specialist ☐Legal Aide/ Disability Rights Ohio ☐Food Pantry ☐Food Stamps ☐Lifeline – Cell Phone ☐Home Energy Assistance ☐Financial Management ☐Household Goods 2 | P a g e Revision Date 04/10/2015 ☒Other ______Applications were made on the resident’s behalf with the following (check all that apply): ☐ Application to the HOME Choice ☐ PAA for PASSPORT/ALW/Waivers and/or PACE ☐ DD Board for IO/Level 1/ Self waivers ☐ ODM for Ohio Home Care Waiver</p><p>RESIDENT ACKNOWLEDGEMENT If In-Person Visit with resident has occurred, please have individual read and sign the following statement:</p><p>My signature is verification that the Community Living Specialist met and shared community resources with me. </p><p>Printed Name of Resident: </p><p>Resident Signature: ______Date: ______</p><p>(NOTE: If resident is unable/refuses to sign, please have a staff member from the nursing facility sign on resident’s behalf.)</p><p>Section B: Community Living Specialist Summary of Barriers and Next Steps 3 | P a g e Revision Date 04/10/2015 Summary of Conversation with Resident/Guardian & Social Worker: Discharge Goals: </p><p>Previous Efforts in the Community: </p><p>Informal Support systems: </p><p>Check all barriers to community living that must be addressed prior to the resident returning to community living: ☐Physical health issues must improve prior to return ☐Lack of independent living skills ☐History of Substance Abuse with risk to relapse – ☐Language or Communication barriers requires coordination in the community care plan ☐Need for accessible housing/home modifications/assistive ☐History and/or current mental health issues requires technology coordination in the community care plan ☐Housing ☐Lack of sufficient income to support community living ☐Lack of informal supports – will need a back-up plan ☐Bad debt – need for credit recovery developed for community living ☐Criminal history may delay housing connections ☐Need for structured residential setting ☐Probate Court issues ☐Need for home and community based waiver program ☐Lack of awareness or unrealistic expectations ☐Possible ineligibility for home and community based waiver regarding disability or needed supports programs ☐Facility/Staff Administration Issues (e.g. poor ☐Wishes to remain in the facility discharge planning) ☐ Homelessness history ☐Lack of support by Guardian and/or Family ☐ Transportation ☐Lack of Support by Physician and/or Psychiatrist ☐ Medication management ☐Hospice ☐Other Do you believe that it is feasible for the resident to return to community living? ☐Yes, resident can return to community living without concern for health and welfare. ☐Yes, but only if the following is in place upon return to community living (Please describe):</p><p>☐No, health and welfare needs cannot be met in a community setting at this time. Be specific about why not. (Please check all that apply): ☐ Requires assistance with most/ all ADLs/IADLs ☐ Safety concerns: danger to self or others ☐ Requires 24/7 care ☐ Family unable to supplement care to safely maintain community living ☐ Resident changed his or her mind about moving to the community ☐ Other (Please describe)</p><p>4 | P a g e Revision Date 04/10/2015</p>