This document summarizes responses from participants at different stations of a pre-meeting interactive learning activity. At Station 1, participants shared reasons for attending the meeting, which largely centered around learning about new resources, strategies, and ideas to help facilitate better transitions for individuals into the community. At Station 2, facilitators of transition efforts mentioned included coordination, communication, supportive services and families, and addressing individual needs and goals. Barriers to transition efforts listed at Station 3 included lack of resources like housing, transportation, and staff knowledge of community options as well as organizational policies and limited funding. Station 4 prompted discussion of emerging principles but no responses were included.

1. Pre-Meeting: Interactive Learning
Carousel

2. Station 1
Why are you here today?

3. Station 1: Why are you here?
I am here because I care about
what I do and how I do it in
transitioning individuals into
community living.

4. Station 1: Why are you here?
To learn about resources for
transitions

5. Station 1: Why are you here?
To learn more resources that are
available for community transitions

6. Station 1: Why are you here today?
Planning to implement a lot with
COPD (high risks + readmission).
New ideas?

7. Station 1: Why are you here today?
To learn and reflect-what do other
people do that works well and I
could do also?

8. To gain knowledge about transition
resources avail
Station 1: Why are you here today?

9. To learn + exchange ideas to share
what tools we have + hopefully learn
more to become better with
transitioning people
Station 1: Why are you here today?

10. Exchange ideas
Station 1: Why are you here today?

11. Develop and/or learn innovative
strategies. How are others doing it
Station 1: Why are you here today?

12. Learn how to better coordinate
successful transitions from SNF’s
Station 1: Why are you here today?

13. To network
Station 1: Why are you here today?

14. To increase my knowledge of
resources for transitioning from
program to another
Station 1: Why are you here today?

15. Network and learn more about
community
Station 1: Why are you here today?

16. Hear more about resources program
in NC
Station 1: Why are you here today?

17. To learn as much as possible to
better asst my patients
Station 1: Why are you here today?

18. To better learn a cohesive path to
ensure smoother transitions for care
& to learn!
Station 1: Why are you here today?

19. To gain more insight on the
transition process, also possibly
network with other transition team
leaders, to also take back some info
to my facility to better meet the
needs of population I serve
(complex patients)
Station 1: Why are you here today?

20. To learn how to overcome obstacles
in transition process
Station 1: Why are you here today?

21. 1. Interested in topics, i.e. Job/work
2. Increase referrals... for MFP
Station 1: Why are you here today?

22. To learn more about transition
planning, things I don’t already
know, and learn from my peers
Station 1: Why are you here today?

23. To become more effective as a
transition coordinator
Station 1: Why are you here today?

24. To increase my knowledge of comm
resources
Station 1: Why are you here today?

25. To hopefully learn ways/techniques
to assist me when pts transition
from one healthcare setting to the
next
Station 1: Why are you here today?

26. To learn more about resources
available in the community for my
residents who are discharging
Station 1: Why are you here today?

27. Station 1: Why are you here?
To learn & share strategies that will
allow for smooth transitions to
home & reduce readmissions

28. Station 1: Why are you here?
Additional info on transition

29. How to better assess which
patients are likely to
successfully transition into the
community
Station 1: Why are you here today?

30. To learn new skills, to present,
and meet others that have a
shared interest in helping
individuals with I/DD and Autism
Station 1: Why are you here today?

31. To gain the skills necessary to
lead individuals & other
professionals into successful
transitions
Station 1: Why are you here today?

32. Learn and grow
Station 1: Why are you here today?

33. To learn how D.C. Senior
Services can play a role in
transitions
Station 1: Why are you here today?

34. To learn resources to better
assist community transitions
Station 1: Why are you here today?

35. Station 1: Why are you here?
Learn, Share, Act

36. Station 1: Why are you here?
To gain better knowledge &
resources for transitions

37. To learn as much about the MFP
process, to be better at my job
Station 1: Why are you here today?

38. To learn more info about the
transition process
Station 1: Why are you here today?

39. Interested in being part of
conversation to address needs
of folk transition
Station 1: Why are you here today?

40. Learn about more resources for
people who are transitioning,
learn how to engage family &
guardians
Station 1: Why are you here today?

41. Try to update peers of incredible
fast pace of hospital difficulty of
stress
Station 1: Why are you here today?

42. To hopefully bring back some
good community resources that
will help myself and my co-
workers in our discharge
planning
Station 1: Why are you here today?

43. Learn how to break down
barriers w/ transitions process
Station 1: Why are you here today?

44. To grow professionally, to learn,
to network
Station 1: Why are you here today?

45. Learn others’ golden nuggets
about best person-centered
practices and applied to quality
transitions into real community
life
Station 1: Why are you here today?

46. To put things in perspective
Station 1: Why are you here today?

47. The potential to affect change
Station 1: Why are you here today?

48. To be able to enhance my
knowledge, improve our
transitions care program, to
expand in all care settings
Station 1: Why are you here today?

49. Station 2
What facilitates (supports)
transition efforts?

50. Station 2: What facilitates
(supports) transition efforts?
Communities

51. Station 2: What facilitates
(supports) transition efforts?
Coordination

52. Station 2: What facilitates
(supports) transition efforts?
Supporting the person’s goals

53. Station 2: What facilitates
(supports) transition efforts?
Getting input from the person
who is transitioning

54. Station 2: What facilitates
(supports) transition efforts?
Resources & referrals

55. Station 2: What facilitates
(supports) transition efforts?
What team members can do &
what their agency can provide

56. Station 2: What facilitates
(supports) transition efforts?
Transition coordinator/agency
developing strong collaborative
partnership

57. Station 2: What facilitates
(supports) transition efforts?
Effective communication b/w
community base providers &
hospitals

58. Station 2: What facilitates
(supports) transition efforts?
Realistic expectations

59. Station 2: What facilitates
(supports) transition efforts?
Knowledge of sustainable
supports

60. Station 2: What facilitates
(supports) transition efforts?
Collaborative work among
agencies

61. Station 2: What facilitates
(supports) transition efforts?
Community effort-everyone on
the same page working toward
the same goal

62. Station 2: What facilitates
(supports) transition efforts?
Staying person-centered

63. Station 2: What facilitates
(supports) transition efforts?
Good action plan & someone
they can call on

64. Station 2: What facilitates
(supports) transition efforts?
Open-minded, not imposing your
belief values

65. Station 2: What facilitates
(supports) transition efforts?
Natural supports & invested
team members

66. Station 2: What facilitates
(supports) transition efforts?
Supportive family

67. Station 2: What facilitates
(supports) transition efforts?
Primary care

68. Station 2: What facilitates
(supports) transition efforts?
Communication

69. Station 2: What facilitates
(supports) transition efforts?
Administrations that understand
the process

70. Station 2: What facilitates
(supports) transition efforts?
A team of people who we can
rely on! As a transition
coordinator, I know some things-
but need a good tam/network to
ask questions

71. Station 2: What facilitates
(supports) transition efforts?
Team work among all players

72. Station 2: What facilitates
(supports) transition efforts?
Relationship and rapport with
individual

73. Station 2: What facilitates
(supports) transition efforts?
Good communication between
programs

74. Station 2: What facilitates
(supports) transition efforts?
Person being open to next level
of care

75. Station 2: What facilitates
(supports) transition efforts?
Other professionals
understanding the program
(MFP, PACE)

76. Station 2: What facilitates
(supports) transition efforts?
The needs of the person needing
transition care

77. Station 2: What facilitates
(supports) transition efforts?
A positive attitude from all team
members so that the person can
be successful

78. Station 2: What facilitates
(supports) transition efforts?
Teamwork and open
communication

79. Station 2: What facilitates
(supports) transition efforts?
The attitudes of the care worker
& the individual transitioning &
knowledge of care worker to
resources available

80. Station 2: What facilitates
(supports) transition efforts?
Addressing barriers

81. Station 2: What facilitates
(supports) transition efforts?
Use of evidenced-based
practices across the continuum

82. Station 2: What facilitates
(supports) transition efforts?
Referrals & coordinating with
resources for a successful
transition

83. Station 2: What facilitates
(supports) transition efforts?
Good communication, available
resources, patient/family buy-
in/support

84. Station 2: What facilitates
(supports) transition efforts?
Involvement of durable medical
providers, such as respiratory
post D/C

85. Station 2: What facilitates
(supports) transition efforts?
Strong support system “family,
church, friends, neighbors”

86. Station 2: What facilitates
(supports) transition efforts?
Natural support, good plan
developed with individual,
monitoring and .... addressing
barriers

87. Station 2: What facilitates
(supports) transition efforts?
Provider agencies,
developmental centers & MCOs

88. Station 2: What facilitates
(supports) transition efforts?
Trust & relation support

89. Station 2: What facilitates
(supports) transition efforts?
Collaboration among supports

90. Station 2: What facilitates
(supports) transition efforts?
People who are willing to take
risks!

91. Station 2: What facilitates
(supports) transition efforts?
Being a knowledgeable guide

92. Station 2: What facilitates
(supports) transition efforts?
Positive attitude, wanting to
learn, avail resources, be
realistic and honest

93. Station 2: What facilitates
(supports) transition efforts?
Consideration of the whole
person and identifying best and
worst scenarios and planning for
the most support possible

94. Station 2: What facilitates
(supports) transition efforts?
Good action plan & someone
they can call on

95. Station 3
What are the barriers (hinders) to
transition efforts?

96. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of staff with base
community resources

97. Station 3: What are the barriers
(hinders) to transition efforts?
Issues with school systems not
being tolerant

98. Station 3: What are the barriers
(hinders) to transition efforts?
No placements available for
adults/children that can meet
needs. Providers saying they
have availability, capability,
experience but don’t

99. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of knowledge of what each
level of care can provide among
providers

100. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of communication or warm
hand off to community-based
providers, hospitalization

101. Station 3: What are the barriers
(hinders) to transition efforts?
Occasional lack of transparency

102. Station 3: What are the barriers
(hinders) to transition efforts?
Political will to remove all the
barriers

103. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of knowledge on possible
purchasing a home

104. Station 3: What are the barriers
(hinders) to transition efforts?
Need for additional technology
rest assured

105. Station 3: What are the barriers
(hinders) to transition efforts?
Money within communities to
provide resources & FTEs

106. Station 3: What are the barriers
(hinders) to transition efforts?
Not identifying needs prior to
discharge, i.e. equipment,
financial capability to pay for
medicines etc.

107. Station 3: What are the barriers
(hinders) to transition efforts?
No funds available within the
time needed for services trying
to access

108. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of resources

109. Station 3: What are the barriers
(hinders) to transition efforts?
Willingness of the person to
apply for resources

110. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of resources,
“transportation”, housing

111. Station 3: What are the barriers
(hinders) to transition efforts?
Medicaid deductible

112. Station 3: What are the barriers
(hinders) to transition efforts?
Categories of support: there are
always people who fall thru the
cracks, don’t qualify-we need to
be creative about making sure
they have needs met!

113. Station 3: What are the barriers
(hinders) to transition efforts?
Limited ICF
(intermediate care facility)
vacancies

114. Station 3: What are the barriers
(hinders) to transition efforts?
No insurance, self pay

115. Station 3: What are the barriers
(hinders) to transition efforts?
No primary care giver but trying
to figure out how to access their
rights

116. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of family/community
support

117. Station 3: What are the barriers
(hinders) to transition efforts?
Low income

118. Station 3: What are the barriers
(hinders) to transition efforts?
Limited resources

119. Station 3: What are the barriers
(hinders) to transition efforts?
Housing/criminal background
before disability

120. Station 3: What are the barriers
(hinders) to transition efforts?
Home repairs

121. Station 3: What are the barriers
(hinders) to transition efforts?
Knowledge of resources, i.e.
Home mod, housing

122. Station 3: What are the barriers
(hinders) to transition efforts?
Organizational policies &
procedures

123. Station 3: What are the barriers
(hinders) to transition efforts?
Organizational policies &
procedures

124. Station 3: What are the barriers
(hinders) to transition efforts?
Transitioning pts from home to
SNF and haven’t seen MD in
months/years

125. Station 3: What are the barriers
(hinders) to transition efforts?
Rural areas with limited
resources especially
transportation

126. Station 3: What are the barriers
(hinders) to transition efforts?
Rural areas (lack of resources)

127. Station 3: What are the barriers
(hinders) to transition efforts?
Communications, lack of
technology in home

128. Station 3: What are the barriers
(hinders) to transition efforts?
Wait time-transition process
takes too long and they get
frustrated

129. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of housing/support
systems

130. Station 3: What are the barriers
(hinders) to transition efforts?
Unrealistic expectation of
person, lack of acceptable
understanding of medical needs

131. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of finances, community
support, and options

132. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of community, family
support

133. Station 3: What are the barriers
(hinders) to transition efforts?
Hospital not aware of community
partners (if person doesn’t tell
staff)

134. Station 3: What are the barriers
(hinders) to transition efforts?
Patient + medical team not
having same goals

135. Station 3: What are the barriers
(hinders) to transition efforts?
Lack willing or capable
caregivers

136. Station 3: What are the barriers
(hinders) to transition efforts?
Lack of transportation

137. Station 3: What are the barriers
(hinders) to transition efforts?
On-going criminal activities

138. Station 3: What are the barriers
(hinders) to transition efforts?
Expectation from everyone
involved

139. Station 3: What are the barriers
(hinders) to transition efforts?
Not enough resources in my
area, medics/Medicaid
restrictions guidelines

140. Station 3: What are the barriers
(hinders) to transition efforts?
Funding, lack of appropriate
services, lack of insight, and
motivation

141. Station 3: What are the barriers
(hinders) to transition efforts?
Time frame for application
approve assessment

142. Station 3: What are the barriers
(hinders) to transition efforts?
Affordable/accessible housing,
community-based personal
assistant services, policy that
limits individual choice

143. Station 3: What are the barriers
(hinders) to transition efforts?
ACTT drift of mission over the
years trying to partner, equip,
encourage staff to join our
“mission”

144. Station 4
Emerging principles

145. Station 4: Emerging principles
What resonates with you the
most? What, if anything, is
missing?

146. Station 4: Emerging principles
Work yourself out of a job

147. Station 4: Emerging principles
Be creative-outside box

148. Station 4: Emerging principles
Flexible

149. Station 4: Emerging principles
Crisis planning

150. Station 4: Emerging principles
If nursing home patient came
from home that was not
safe/cannot go back

151. Station 4: Emerging principles
Optimistically honest

152. Station 4: Emerging principles
Resonates most, being
optimistically honest-if people,
family know, it’s better for them
to plan

153. Station 4: Emerging principles
Assessment-building
relationship

154. Station 4: Emerging principles
Optimistic honesty + education

155. Station 4: Emerging principles
Not chaotic or sluggish, keeping
momentum going hard

156. Station 4: Emerging principles
Center is person & family

157. Station 4: Emerging principles
Participant in the middle (harder
than it looks)

158. Station 4: Emerging principles
Individual is guiding the goals

159. Station 4: Emerging principles
Empowering person to take
responsibility

160. Station 4: Emerging principles
Making LTC facilities know about
transitions opportunities-for
public too

161. Station 4: Emerging principles
Community-based services,
housing, transportation,
individual choice

162. Station 4: Emerging principles
Holistic perspective

163. Station 4: Emerging principles
Put everything in place

164. Station 4: Emerging principles
Warm hand offs

165. Station 4: Emerging principles
Collaborating with others

166. Station 4: Emerging principles
Relationship building with
participant—family

167. Station 4: Emerging principles
Communication & other systems
SS/DSS/AEC, etc.

168. Station 4: Emerging principles
Need to know continuity of
resource knowledge &
communication

169. Station 4: Emerging principles
Don’t have to be an expert in
everything

170. Station 4: Emerging principles
Teamwork

171. Station 4: Emerging principles
Communication, funds, step out
of the box, ...

172. Station 4: Emerging principles
There should be conversations with
guardians/people about transition prior to
making application. Sometimes when I
come to initial meetings-the
guardian/person has no idea why I am
there and I have to awkwardly explain.
There should be several initial
conversations with the team prior to
beginning the MFP process.

173. Station 4: Emerging principles
Tracking outcomes to provide
evidence-based practices