Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waiver
Service Coordination NHTD
Assistance with the development and implementation of a person–centered individualized Service Plan that will lead to the waiver participant’s independence, integration into the community, health and welfare.
Service Coordination TBI
Provides ongoing assistance with a person–centered individualized Service Plan. The Service Coordinator assists the prospective participant to become a waiver participant and coordinates and monitors the provision of all services in the Service Plan. The goal is to increase the participant’s independence, productivity and integration into the community while maintaining the health and welfare of the individual.
Home and Community Support Services (HCSS) NHTD
Home and Community Support Services (HCSS) are utilized when oversight and/or supervision as a discrete service is necessary to maintain the health and welfare of the participant living in the community. Oversight and/or supervision is necessary to prevent a cognitively impaired individual from unsafe activities (for example wandering or leaving the stove on unattended). Oversight and/or supervision can be accomplished through cueing, prompting, direction and instruction. If the applicant/participant does not require oversight and/or supervision, HCSS would not be appropriate.
HCSS is complementary but not duplicative of other services. HCSS is not to be used as a companion service.
Home and Community Support Services (HCSS) TBI
Home and Community Support Services (HCSS) are only appropriate when oversight and/or supervision is necessary as a discrete service to maintain the health and welfare of a participant living in the community. HCSS may also include personal care assistance with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). HCSS is not a companion service. The service must be provided under the direction and supervision of a Registered Professional Nurse (RN) based on an assessment of the individual’s needs and supported by physician orders.
Oversight and/or supervision is necessary to protect a cognitively impaired individual from adverse outcomes related to his/her activities (for example, wandering or leaving the stove on unattended). Oversight and/or supervision includes cueing, prompting, directing and instructing. If a participant’s need for oversight/supervision warrant HCSS during the night, the HCSS staff must remain awake throughout the duration of time assigned to the participant.