Transitioning from Institution to the Community

Many states are emphasizing the need for more community integration and reducing the number of people who are in state hospitals for the mentally disabled.  This is a challenge for both the human service professionals tasked with coordinating the transition as well as the client. In some cases, people have spent decades in state institutions and will have to adjust to life back in the community.  There are also some situations when the institution was used as the most appropriate alternative to incarceration.  Whatever the reason for institutionalization, it requires a great deal of coordination between the case manager and other agencies on the treatment team when the time comes to return to the community.  I will review the general steps taken when transitioning someone from an institution back into the community.

Determine Eligibility
One of the first steps in the transition process is to determine eligibility for services.  The case manager reviews documentation such as psychological reports and any other reports available from the hospital to determine the most appropriate services after discharge. The case manager might also conduct needs assessments to determine eligibility. Level of functioning assessments are often utilized to determine eligibility for Intellectual Disability Services.   These assessments are also referred to as functional assessments. Functional assessments vary from state to state but generally cover the following areas to determine eligibility for services:

*Medical- This area covers any health related issues that requires assistance from support staff or other health professionals. Some areas of need that might be evaluated include:
   1. Assistance with medication administration

   2. Assistance with eating

   3. Chronic medical conditions (asthma, diabetes, obesity, etc.)

*Task Learning- This area measures the ability to follow instructions such as completing one to two step instructions, simple math, telling time, etc.  

*Self-Care- This section measures the client’s ability to complete hygiene activities on their own or if support is needed.

*Communication- This area evaluates the client’s ability to communicate verbally or through gestures or signs. Limited communication skills will likely result in meeting a high level of need in this area.

*Mobility- The ability to walk or operate a wheelchair as well as other movements such as getting up from a seated position or positioning in the bed is determined in this section of the assessment.

*Behavior- Any history of aggressive or inappropriate behaviors will met the level of need in this area.

*Community Living Skills- This area measures the ability to live independently and the level of support needed to complete normal activities of daily living.

Coordinate Funding
After completing functional assessments to determine eligibility, the funding source must be determined.  From my experience, clients who are dually diagnosed with intellectual disability and a mental health or substance abuse tend to benefit from  Medicaid Waiver services. The waiver services tend to provide a wider range of services than mental health services.
Clients with just a mental health diagnosis will need additional assistance applying for  housing assistance and assistance with obtaining benefits.  

Assist with Finding a Provider
Typically before discharge, the case manager might assist with finding a residential provider. In most situations, a potential residential provider must be established before a hospital will approve the discharge.  Case managers can assist in this process by providing information on available resources, locating homes with vacancies, and coordinating tours. The hospital staff will most likely be responsible for accompanying the client on the tours before discharge.

Coordinating Support Services
Once the provider has been located and chosen, case managers then take over and coordinate the admission to the new community home placement.  Just some of the coordination efforts include:

*Applying for Medicaid (If Applicable)

*Confirming discharge/move in dates

*Authorize Services (If Applicable for Waiver services)

*Developing a Treatment Plan

*Assist with finding additional support services such as day support, employment, counseling, etc. 



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Martin Gardner
Thanks for visiting Case Management Basics! Martin Gardner is the founder of and Case Management Basics, LLC. Gardner is a mental health professional with over 20 years of experience in the human services field.

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