A Guardian/Parent or Family Member

An independent person working

Options and Choice

As a guardian/parent or family member nothing is more important than the safety of your loved one. Parents and guardians of State Operated Developmental Center residents will continue have choice throughout this process to ensure the safety of their loved ones.

We have and remain committed to working with you in honoring your choice of the the service options your loved one is eligible. Those options could include:

Home and Community-Based Services Options:

  • Community Integrated Living Arrangements (CILA) which is a living arrangement in a group home, family home or apartment that provides up to 24-hour services and support from a qualified and willing provider of your choice.
  • Home-Based Support Services in which you have a monthly maximum amount of money to use for services, such as day programs, professional services and direct services.
  • Day habilitation and other Day Services

Non Home and Community-Based Options:

  • Another State Operated Developmental Center (SODC) similar to your current SODC's level of care.
  • A privately operated Intermediate Care Facility for the Developmentally Disabled (ICF/DD) located in the community.
  • Skilled Nursing Facility (SNF).

If you prefer one of the above Non Home and Community-Based Options, the PAS/Independent Service Coordination (ISC) agency and the SODC staff will work with you to secure those service options.

New & Dynamic Transition Process

We have created a new & dynamic transition process for developing community based service & supports called Active Community Care Transitions (ACCT)

 that is:

  • personalized to each individual's wants and needs
  • family-focused
  • guided by principles and values
  • maximizing an individual's control over their transition

Active Community Care Transitions (ACCT)

  • The ACCT process begins with an independent, comprehensive needs evaluation.
  • This evaluation is key to the design of a customized community living plan for your loved one.
  • The evaluation starts with the person as the center of the conversation.
  • Trained and experienced facilitators engage the person, their family/guardian and SODC staff, in a discussion that serves as the blueprint to design a community living plan that will provide the individual with the appropriate services and support they will need to be successful.

Through discussion and conversation at the meeting we learn the following from participants about the person:

  • dreams and goals,
  • fears,
  • strengths and weakness,
  • hopes and aspirations,
  • successes and failures,
  • what works and does not work,
  • personal preferences,
  • interests,
  • what excites the person,
  • and more

Since the information discussed is highly individualized and personal, the result is the development of what is titled a Person-Centered Plan (PCP).Medical staff person reviewing clinical information

In addition, the ACCT process consists of individual assessments across all areas of an individual's daily life that includes:

  • Careful analysis of the current and past records to determine individual needs; 
  • Securing of new or additional clinical information, data and recommendations for support by experts in various areas of need.

So what do we do with all this information once this comprehensive evaluation process is completed?

  • The information from the PCP, individual assessments, housing, employment and community preferences are combined into a document called an "individual budget support plan narrative" which serves as a roadmap to the services the individual will receive in the community.
  • In addition, an "individual planning budget" ("IPB") is prepared to identify the costs which will result from implementation of the individual budget support plan narrative.
  • The completed individual budget support plan narrative is then reviewed by the SODC Inter-Disciplinary Team (IDT) and others to ensure all areas of need are addressed and provided for in the community plan.

The next step is to see which providers will implement the community living plan.

We have a talented pool of fully licensed providers across the state who have committed to participate in the ACCT process.

You are probably wondering if you have some say in choosing the provider.

Absolutely! We encourage provider exploration.

Providers who have expertise in areas necessary to meet your loved ones individual's needs will be identified, from which you, as the parent/guardian, will be able to choose which provider will implement the community living plan.

  • Visit and/or research identified potential providers and get to know them. Our team can help set that up.  Listing of ACCT Providers.
  • We also encourage potential providers to visit your loved one, review various assessments and records and meet with team members.
  • After the initial potential provider exploration, you and your loved one will be asked to confirm interest in a provider and the provider to confirm continued interest in potentially serving your loved one.
Home Environment

So where is your loved one going to live?

  • During the PCP process, you will have shared your preferred location and the type of living environment you and your loved would like.
  • Based on the information shared, the selected provider will either offer you an opportunity in an existing home they operate or develop a home based on the needs identified in your loved ones community living plan.
  • The majority of the transitions will be to homes developed for your loved one.

A few thoughts about community living locations:

  • Our desire is to identify a community that would be within a 30-45 minute travel time from the family/guardian.
  • A key element for success is not just the physical location of the home, but the community supports that are available, including access to medical, dental, psychiatric care and programming or activities that are of interest to the individual.
  • The most important thing is that this is determined with each person and their guardian.
Bedroom for an Individual

A few thoughts about the home:

  • The intention through the ACCT process is to develop smaller settings of no more than four persons.
  • Each person will have their own bedroom.
  • If there are circumstances in which alternatives need to be considered they are addressed on a case by case basis.

So who are the people who will be working with your loved one in their home?

  • Providers will work with the ACCT team in determining the profile of skills and attributes of the potential staff.
  • We encourage the person and families/guardian to engage in the interview and selection process of potential staff or support personnel.
  • All staff that are hired are required to go through hours of training and a comprehensive background check.

Once the home and services are developed as outlined in the community living plan, a pre-transition visit is scheduled.

The pre-transition visit may vary for your loved one, depending on whether they are moving into an existing CILA or a home created specifically around their needs.

  • If your loved one is moving into an existing CILA, they will be able to visit for short periods of time for dinner, a movie with their new roommates or an overnight visit prior to moving in. 
  • If a home has been created for your loved one, based on their community living plan, the first visit may be an extended one, which ultimately will lead to discharge once it is clear your loved one is doing well in their new home. 
Bobbie in the kitchen of his home

A few additional things to know about pre-transition visits:

  • Pre-transition visits are individualized and based on the needs of your loved one, which can last from a few hours to several weeks.
  • During the pre-transition visit, significant monitoring, feedback and support is provided to the home to ensure a successful transition.

Once your loved one, you, and the provider feel comfortable with the home, staff and support, the discharge process begins.

The discharge is just the beginning step in your loved ones  life in the community.

  • We want to make sure your loved one continues to do well.
  • Therefore we have established extensive follow-along services.

What do we mean by extensive follow-along?

Community Living
  • During the first eight (8) weeks in the new community setting, your loved one will receive weekly face-to-face visits from the Pre-Admission Screening (PAS)/Independent Service Coordination (ISC) agency.
  • If your loved one experiences transition difficulties, the PAS/ISC agency representative will continue to conduct face-to-face on-site visits with your loved one until such time the provider, you and ACCT Team are comfortable with the transition progress.
  • During these visits, staff will review medication changes, dietary changes, daily activities, social functioning, individual's satisfaction, safety and behavior patterns.
  • In addition, during the first four (4) weeks in the new community setting, your loved one may also receive weekly face-to-face visits from Division of Developmental Disabilities staff in the Bureau of Transition Services (BTS) and ACCT Team members.
  • During the following eleven (11) months, PAS/ISC agency staff will visit on a monthly basis. Visits are quarterly after the first year unless the situation warrants greater frequency. Visits include review of individual's overall well being and other concerns.
  • In addition, during the first four (4) weeks in the new community setting, your loved one may also receive weekly face-to-face visits from an SODC social worker or Habilitation Plan Coordinator (HPC) who is familiar with your loved one.

The goal of the ACCT process is not simply to change the location or address of your loved one. It is to offer the needed community supports and services that will allow your loved one to be close to their family, to participate in their community and to lead an ordinary life.

Read the full description of the Active Community Care Transitions Process.  Review our Media Resources for more information and the Moving Forward Active Community Care Transition Video.