Nursing Home Residents Looking to Transition
Community

Who Is Eligible for the Living Choice Program?

Eligibility is determined by the Oklahoma Health Care Authority based on four components:

  1. The person must be at least 19 years of age
  2. The person must reside in an institution for at least six months prior to his/her proposed transition date (nursing facility or state institution)
  3. The person must be approved for long-term care services provided by SoonerCare for at least one month prior to transition and
  4. The person must continue to need at least the level of care which resulted in admission to the institution

Once a person who wishes to transition is identified, a Transition Coordinator will contact the person and begin the process to support the person in developing a Transition Plan.

How Does Someone Apply?

A person can apply through Oklahoma Health Care Authority by calling (888) 287-2443. Ask to speak to someone about the Living Choice Project. They will complete a phone interview to gather basic information to determine eligibility. Visit www.OKHCA.org for more information about the Living Choice Project.

What Happens After Someone Applies?

Once a person is determined eligible for the Program, then the Transition Coordinator Agency will be notified to visit the person at the facility and conduct an orientation to the Program. If the person chooses to move forward, then the Transition Coordinator will support the person in beginning the transition process.

Can Someone Be Removed from the Project?

A person can be removed from the program when:

  • The person is admitted to institution for more than 30 consecutive days
  • The person is incarcerated
  • The person is determined to no longer meet SoonerCare financial eligibility for home and community-base services
  • The person is determined by the Social Security Administration to no longer have a disability qualifying the person for services under the Living Choice Project
  • The person is determined by the Oklahoma Health Care Authority Level of Care Evaluation Unit to no longer be eligible
  • The person moves out of state

Can Someone Re-enroll into the Project?

Re-enrollment in the Living Choice Project can occur when:

  • The reason for the person’s re-institutionalization is documented in the revised Transition Plan
  • The person, the Transition Coordinator and the Transition Planning Team determine whether or not the individual can safely return to the community
  • In situations where a person requires hospitalization and convalescent care, the community-based placement remains intact as long as the person’ re-institutionalization does not exceed six months

Who All Is Involved in the Living Choice Program?

Participant (the person choosing to transition to the community)

Chooses to Participate in planning for the transition, completes an assessment with support from the coordinator, if needed, chooses Team members to assist in the planning, creates a Transition Plan, monitor’s the Transition Plan, complete assigned Team activities, create Community Plan, and…finally, transition to the community.

Oklahoma Health Care Authority (the Oklahoma Medicaid Agency)

Complete referral intakes (applications), manage the Living Choice Program, determine Program eligibility, reimburse Providers, resolve complaints, manage Program finances, contract and arrange for service delivery by qualified providers, and Program quality assurance and Improvement

Transition Coordinator (works for a provider agency)

Participate in Living Choice training, orient the participant to the Living Choice Program, support the person in assessing readiness for transition, support the person in creating a Transition Plan and a Community Plan. The Transition Plan includes plans for transitioning out; the Community Plan includes plans for the day of transition and thereafter. They will also assist in coordinating the needed community services upon transition.

Transition Team

The team is made up of people involved in the person’s life. This could be family, friends, nursing facility staff, etc. The person chooses who he/she would like to have on the team. The team then creates the Transition Plan, completes assigned team responsibilities as determined by the team, creates the Community Plan and helps monitor the success of the plan. They also advocate for the person, if needed.

Transition Coordinator Supervisor (supervises the Transition Coordinator)

Ensures Transition Coordinator follows processes, ensures the Transition Plan is effective based on Team development, ensures monitoring occurs as determined by the Team, ensures an effective Community Plan is created by the Team.

Centers for Independent Living

Provides Transition Coordination Services to the person, if requested, provides Peer Support Services to persons, as requested, provides independent living skills training, if requested, and provides self-advocacy training, if requested. Centers for Independent Living are funded by federal and state dollars to support independent living of adults with disabilities. Learn more about Centers for Independent Living at http://www.ilusa.com/links/ilcenters.htm
The Oklahoma Independent Living Centers involved in the Living Choice Program are:

  • Ability Resources, Inc – Tulsa
  • Oklahomans for Independent Living – McAlester
  • Progressive Independence – Norman

Home and Community Based Providers (provider agencies)

These agencies provide community-based services to people living in the community. They contract with the Oklahoma Health Care Authority (OKHCA) to provide transition services, manage the coordinators, bill OKHCA for services delivered and manage the quality of their service.

Long Term Care Authority of Tulsa

Contracts with OKHCA to provide Transition Coordinator training, authorize the Community Plan and provide technical assistance to the coordinators.