To start your journey of compassionate care with the NHTD waiver program, you need to go through an assessment. This first step may make you feel uncertain, but it is essential to provide the personalized care you deserve. For the Nursing Home Transition and Diversion (NHTD) waiver program, this assessment and care planning process is the foundation of your overall experience. This is because it involves hearing your needs and goals to tailor your care plan. Read this guide to learn how NHTD assessment and care planning are built to provide you with personalized care services. Reach out today to learn more about how we can help you enhance your golden years.
What is the Purpose of the NHTD Assessment?
The purpose of the NHTD assessment is to determine that the individual is eligible for the NHTD waiver program (a New York state initiative to ensure individuals with disabilities and seniors can avoid residing or transition to their community from nursing home care while receiving nursing home-level of care). Additionally, this assessment also gathers the details required to make a person-centered plan of care. This way, NHTD officials identify individuals who need a nursing home level of care and thrive in the community with the right support.
The Two Key Phases: Assessment and Care Planning
The assessment and care planning in the NHTD program requires a collaborative effort, involving you, your family, the Regional Resource Development Center (RRDC), and a Service Coordinator, all working together. The process is divided into two phases.
Phase 1: The Initial Assessment with the RRDC
The RRDC is the official organization that conducts the assessment with a registered nurse to determine your eligibility for the NHTD waiver program.
During the RRDC assessment, here are the things you can expect:
In-Person Meeting: An RRDC registered nurse will visit you to examine and monitor your current setting, whether it is your home, a hospital, or a rehabilitation facility. This meeting is more like a discussion rather than a clinical evaluation.
Determining level of care: The nurse’s primary task is to assess your health to determine whether you meet the requirements of nursing facility level of care (NFLOC) for this program or not. They will ask questions about your health conditions, mobility, and ability to perform daily tasks like bathing, dressing, and preparing meals. This assessment is crucial for all applicants, including those with traumatic brain injury (TBI).
Evaluating for Safety: The nurse will also check whether you receive care for safety in your community or not. They will consider whether your living environment supports your need for well-being at home or not.
Reviewing Medical History: The nurse also discusses your medical history, current diagnoses, and any recent hospitalizations. This way, the RRDC will review your medical history from your doctors to support their findings.
Once the RRDC nurse confirms your eligibility, you move on to the next phase of choosing a Service Coordinator from a service coordinator agency to develop your care plan.
Phase 2: Developing your Individualized Service Plan (ISP)
In this phase, you work with a service coordinator to develop your Individualized Service Plan (ISP). This is the official document that structures your goals and details of every service you will receive.
To craft your ISP, your service coordinator plays a major role as your dedicated advocate and guide. They will listen to your requirements, guide you on what services will fulfil your requirements, and tailor a formal plan of care.
These are the steps that follow in creating your ISP:
Person-Centered Discussion: Your service coordinator will have an in-depth discussion about your requirements with you and your family members. This discussion will involve your strengths, needs, and personal goals for health and independence.
Identifying Services: Based on your goals and assessed needs, your coordinator will guide you about the available NHTD waiver services. Once you learn all about the services, you can discuss the services based on your unique requirements.
Drafting the plan: After the discussion, the service coordinator will draft the ISP, which includes:
Your personal goals.
The specific services you will get, such as Home Health Aide hours, physical therapy sessions, etc.
The providers that were recommended for you to provide those services.
The frequency and duration of each service.
A risk management plan to address your safety concerns.
Review and approval: Lastly, the RRDC staff will review the draft ISP with your coordinator to ensure that the care plan is based on your wishes. Once it’s approved, the plan will be submitted for final review in the RRDC. The RRDC ensures that the plan is appropriate within the program’s cost guidelines based on established NHTD rates.
After the final review, your ISP will be approved, and your services will officially start. This plan will be reviewed with you once every six months by your service coordinator to ensure that it meets your changing needs.
Your Partner in Creating a Plan for Success
We believe that to make any plan for success, you need to work as a team with capable people. The NHTD assessment and care planning process is designed to empower you with the right to choose your care that ensures your independence. From your initial evaluation by the RRDC nurse to working with the service coordinator to develop your care plan. This thoroughly person-centered approach ensures that the NHTD program provides more than just services: they provide a pathway for more independent, dignified, and fulfilling lives at home.
Our team is committed to guiding you through this process to receive compassionate care and support. We can work closely with you, your family, and providers to ensure you have a seamless and supportive experience through the process. Contact us on 718-922-9200 to learn how we can help you with the journey of the NHTD waiver program. You can also send an email to us at info@HouseCallshc.org for more information. Our goal is to help you find the best support for your needs.
