Attachment+A+-+TDP+Scope+of+Work.docx

Attachment A: North Dakota Transition and Diversion Program (TDP)

Purpose The purpose of the North Dakota TDP is to increase transitions from provider operated group facilities (Group Living Location) to home and community-based settings. This service also assists individuals with disabilities in direct threat of institutionalization to remain in the community. The service also assists with a move to a more appropriate community-based setting from a substandard living situation or to a home that meets newly developed accessibility needs, or from a living situation that poses an imminent safety risk verified by the transition provider. The funds for these services are meant to be flexible and utilized by North Dakota TDP teams to address unexpected needs that arise in the move to a less restrictive setting.

Referrals Referrals for North Dakota TDP will be directed to the Aging and Disabilities Resource Link (ADRL) staff or website. ADRL staff will make referrals to the Adult and Aging Services Program staff designed to manage this service for assignment to the agency providing services in the corresponding area of the state.

Process Management Transition Coordinators are required to follow the TDP services policy established by State. This shall include utilizing the Therap system to enter documents, spending requests, and case notes within policy/program timelines. The process will vary depending on the type of service they are receiving through the North Dakota TDP and if the individual being assisted is a target population member as defined in the Department of Justice Settlement Agreement with the State of North Dakota. Process timelines will be provided by State.

Individuals transitioning through the North Dakota TDP from a nursing facility, who are qualified as a Target Population Member as defined in the Department of Justice Settlement Agreement with the State of North Dakota, are required to have a functional assessment, Money Follows the Person (MFP) Transition Plan, and Risk Assessment and Health and Safety Plan completed and updated, as needed, in the Therap System. The Therap system shall be utilized for all documentation, including completing case notes required by State MFP transition process. These process guidelines may be adjusted and modified, as needed.

Therap Case Management System All staff involved with the North Dakota TDP will be provided access to the Therap system to complete the required documentation. Staff will be provided with training on how to utilize the Therap System and related documentation requirements in Therap by State staff.

Billing Requests for the one-time moving costs shall be made through the designed Adult and Aging Services Program Administrator utilizing the spending request form (SFN 542) provided for this purpose. Once the approval is received, the agency can make the purchases and request reimbursement utilizing SFN 1763 and related documentation of spending.

Staff time and other costs shall be billed utilizing the SFN 1763 and related supporting documents to affirm spending.

Services

Transition Coordination Services The Intended Source will be provided funding for two full-time positions that will be dedicated solely to the North Dakota TDP process activities. These positions shall be responsible for delivering transition coordination services in accordance with the most current North Dakota TDP policy and process guidelines, which may be updated, as needed.

The Intended Source is expected to always ensure continuity of services, including during periods of staff turnover. Intended Source shall remain responsible for maintaining uninterrupted service delivery through temporary coverage or other means. Payment will be prorated based on the actual time the positions are filled and staffed, during times when a position is vacant.

Or

TDP Transition Coordination services will be paid at the most current rate for waiver service of Community Transition Services for each 15 minutes of service. The Rural Differential rate can be utilized for all qualified visits that meet the Rural Differential requirements. This service can be provided by any Intended Source employee determined to have the skills to provide this service by the Intended Source Executive Director. This service is payable for the time to assist with transition or diversion and for no more than 90 days of follow-up after transition or diversion. Additional time beyond 90 days can be approved by the State Program Administrator for individuals not moving from a nursing home and for no more than 180 days after transition for any individual transitioning from a nursing home.

Onetime Moving Costs:

Payment for return to community costs to enable successful return to community living. Expenses will be paid at actual cost of items or activity purchased. Spending will be up to $1,500 per transition with additional funding approved on a case-by-case basis.