Verify member’s eligibility and validate that member has been in the facility for at least 60 days, custodial at least one day, and verify income.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
4.
Provide member/authorized representative with network listing of appropriate ALF’s based on member’s needs.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
5.
Complete post transition visit within 5 business days of transition date.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
6.
Notify the Nursing Home Social Worker (NHSW) that member is interested in NHT on the day the member/family request NHT Referral as there is already an establish rapport
A.
NHT Specialist
B.
Care Coordinator
C.
Both
7.
Confirm member’s PCP 7 day post transition appointment has been scheduled.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
8.
Post transition: Update any additional contacts in TruCare.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
9.
Update 701b at 5 day follow up and upload into TruCare.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
10.
Update member address & location in TC; complete LTSS Transition note with status update “complete”; submit task to eligibility to complete 2515.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
11.
If Home Modifications are needed submit request to UM LTC for review immediately upon receipt
A.
NHT Specialist
B.
Care Coordinator
C.
Both
12.
Complete Emergency Disaster Plan note based on new location.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
13.
Review TC documentation, assessment and confirm contact information.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
14.
Obtain prescriptions for DME and Skilled Services (if indicated) and submit to UM –PA for review.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
15.
Confirm all HCBS services are in place and that the member has received all necessary DME & medications according to physician discharge orders.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
16.
Mail copy of PCCP to new PCP and ALF (if applicable).
A.
NHT Specialist
B.
Care Coordinator
C.
Both
17.
Submit task to LTC Intake Queue for case transfer.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
18.
Complete Freedom of Choice form & obtain signature; Review OTC benefit.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
19.
Provide copy of Member Handbook and review with member/POA.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
20.
Educate member on the use of funds as needs for independent living.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
21.
Contact member and/or POA within 24 hours of receipt of referral & schedule onsite visit within 5 business days to complete NHT assessment and PCCP.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
22.
Complete Transition Fund Request form, upload to documents, and task LTC Transition Queue, Activity: Benefit Assistance.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
23.
Complete the NHT Purchase Menu with member.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
24.
Set target discharge date via TC task.
A.
NHT Specialist
B.
Care Coordinator
C.
Both
25.
Complete the LTSS Transition Tracking note in TruCare.
