Transition to Community Setting

Settlement Agreement Provision

IV.C.1-7

About Transition to Community Setting

DBHDS is committed to supporting individuals to successfully transition from training centers to more integrated community homes.  The steps required to achieve this have been broken down into a 12-week process and includes meetings, tours, visits, and training as well as a robust post move monitoring process.  The individual’s health, safety and wellbeing are closely monitored during each part of the transition process. Although the steps included in the 12 week process are mandatory, the order, timeframes and manner in which they are accomplished may be altered to accommodate the needs of the individual or other circumstances that are unique to a particular service provider or transition.  The process must be person-centered.

Training Center and other designated DBHDS community integration staff conduct Post Move Monitoring (PMM) and follow up for a minimum of one year for all individuals discharged from a training center to a community home.  A minimum of four face-to-face visits with the individual are completed within the first 60 days to assess acclimation to the new home, ensure the provision of all identified essential supports and offer additional support or training as needed.  Designated staff also follow up on any reported incidents requiring medical treatment and findings are shared with the Office of Licensing and Office of Human Rights. 

PMM visits are also conducted by advocates with the Office of Human Rights and the Community Services Board (CSB) Support Coordinator (SC).  In order to validate the reliability of the PMM process and identify gaps in care, a PMM Look-Behind Committee reviews a sample of all PMM reports to identify inconsistencies, determine the cause of those inconsistencies and develop an action plan to address any concerns. 

Authorizing Authority

Processes, Protocols and Standards

Guidelines, Charters, Plans, Other

Instruments and Tools

Training Materials

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