NHT Outreach Form
December 2016
Table of Contents
Welcome
Resources
Nursing Home Transition (NHT) Outreach Form
Objectives
Overview of the NHT Outreach Form
About the Form
Completing the Form
Overview of the Form Review Activity
Key Data Collection Questions
Completing Key Questions
Section 1
Section 2
Section 3
Section 4
Section 5
Purpose of Data
Program Justification
Program Funding
Program Evaluation
Agency and Program Reports
Key Data Collection Questions Review Activity
NHT Outreach Form Module Summary
Congratulations!
Welcome
Resources
Various websites are mentioned throughout the training modules. To ensure that the links to these sites remain accurate and active, we have placed them in a separate document on this website. Website links can be found in the NHT Useful Resources document.
Nursing Home Transition (NHT) Outreach Form
Welcome to Module 4 of the Nursing Home Transition (NHT) online training series. This online training series is intended for NHT Coordinators and Supervisors.
The purpose of this module is to review the NHT Outreach Form, including when the form should be completed and by whom. We will also cover key questions that should be completed on the form and why.
Objectives
Please take a moment to review the objectives for the Nursing Home Transition Outreach Form module.
- Explain what the NHT Outreach Form is.
- Briefly describe the sections of the form and when they are to be completed.
- Identify the key questions on the form that provide data to the Centers for Medicare and Medicaid Services (CMS).
- Explain why the data collected in the NHT Outreach Form is important.
Overview of the NHT Outreach Form
Let’s begin by exploring the form including:
- What it is,
- Who should complete it, and
- What type of data is collected, and when.
About the Form
The NHT Outreach Form is a mandatory form that must be completed by the NHT Coordinator (NHTC) in SAMS. The form is used to collect data on NHT participants that meet all of the following required criteria:
- The NHT coordinator informed the participant about the nursing home transition process.
- The participant decided to transition to the community from a nursing facility.
- The participant received transition coordination services.
- The participant began a transition plan.
It is important to collect information on all NHT participants who receive transition coordination services, regardless of whether or not those individuals actually complete the transition, receive any other services, or enter a waiver or other state or federally-funded program. NHT service coordination includes information and transition coordination activities, such as helping a participant complete applications or forms.
With the exception of participants who are Money Follows the Person (MFP) and entering Living Independence for the Elderly (LIFE), the NHT Outreach Form should NOT be completed if the individual’s transition was a normally scheduled nursing facility discharge and did not require NHT support or intervention.
Completing the Form
The NHT Outreach Form consists of five sections.
Section 1 of the form documents initial participant data.
NHTCs complete Section 1 once the participant and/or family has made an informed decision to transition the participant to the community and it has been determined that the individual meets the NHT participant criteria.
Section 2 of the form documents general NHT information and nursing facility data.
NHTCs complete Section 2 once the participant and/or family has made an informed decision to transition the participant to the community and it has been determined that the individual meets the NHT participant criteria.
Section 3 of the form documents transition data.
NHTCs complete Section 3 the day of, or immediately after, transition.
Section 4 of the form documents closeout information, including housing data.
NHTCs complete Section 4 the day of, or immediately after, transition.
Section 5 of the form documents Money Follows the Person (MFP) information and required additional post-transition data.
NHTCs complete Section 5 the day of, or immediately after, transition.
Overview of the Form Review Activity
Before moving on to the next section, take a few moments to check your understanding of the NHT Outreach Form by completing these review questions.
1. True or False? If an NHT participant does not transition, the NHT Outreach Form does not need to be completed.
Please pause.
The correct answer is False. The NHT Outreach Form collects information on all transition candidates who receive transition coordination services, regardless of whether or not those individuals actually complete the transition.
2. Please select the correct description for each Section.
Sections
Section 1
Section 2
Section 3
Section 4
Section 5
Descriptions
Closeout Information
NHT Information
Post-Transition/MFP Data Participant Identification
Transition Data
Please pause.
The correct answers is:
Section 1 documents initial participant information.
Section 2 documents general NHT information and nursing facility data.
Section 3 documents transition data.
Section 4 documents closeout information, including housing data.
Section 5 documents required additional post-transition/MFP data.
Sections 1 and 2 of the form are completed when an individual states he or she wants to transition and Sections 3, 4, and 5 of the form are completed the day of, or immediately after, transition.
Key Data Collection Questions
Now that we have reviewed the NHT Outreach Form, let’s explore the key questions within each section that should be completed by the NHT coordinator and why it is important to collect this data.
Completing Key Questions
While it is required to complete the entire NHT Outreach Form, there are key questions within each section of the form that require special attention and must be completed and answered correctly in order to report a successful transition, identify program barriers, and evaluate the utilization of housing resources.
Section 1
Questions that must be answered correctly in Section 1 of the form in order to report a successful transition are 1.A.1 and 1.A.8.
For question 1.A.1, you need to enter the date when the participant consented to transition into the community from a nursing home facility.
For question 1.A.8, you must ensure that you enter a valid Medicaid number.
Section 2
In Section 2 of the form, make sure that you answer question 2.A.1 accurately in order to ensure a transition is reported successfully.
For question 2.A.2, you need to ensure that you enter the participant’s nursing facility admission date correctly.
Section 3
In order to report a successful transition, the following questions must be answered correctly in Section 3 of the form: on Page 2, questions 3.A.4 and 3.A.6, on Page 3, questions 3.A.12 and 3.A.13.
For question 3.A.4, you must answer “yes” that the consumer completed the transition to the community. Make sure that you skip to question 3.A.6 and that you leave 3.A.5 blank.
For question 3.A.6, you need to enter the date the consumer completed his or her transition into the community.
For question 3.A.12, you need to enter the waiver or program to which the participant transitioned. If the program is not listed, select “Other” and document the program details in the Notes section.
For question 3.A.13, you need to list all barriers that were overcome for the participant’s safe transition into the community. Select “Other” and document any barriers not listed on the form in the Notes section.
For those individuals that do NOT transition, it is very important to complete questions 3.A.4 and 3.A.5.
For question 3.A.4, you must answer “no” the consumer did NOT transition to the community.
For question 3.A.5, you need to document all barriers that prevented the consumer from transitioning into the community. Document details and any barriers not listed on the form in the Notes section. Keep in mind that additional barriers specific to Money Follows the Person (MFP) will be documented in question 5.A.2. The data collected for this question is sent to CMS for MFP. In addition, it provides the Office of Long-Term Living (OLTL) and CMS with important information regarding barriers to transitioning that they may be able to address with future programs and services.
Section 4
Data from Section 4 housing questions is collected to provide information to OLTL, stakeholders, and NHT Coordination Agencies (NHTCAs). For example, OLTL uses information from section 4 to help evaluate the utilization of housing programs and housing resources.
Questions from Section 4 that are important to complete include 4.A.2, 4.A.3, and 4.A.5.
For question 4.A.2, you need to indicate if the participant needed assistance from an NHT coordinator in locating or securing housing. This includes but is not limited to providing a housing list, securing deposits, and/or assisting with applications or other forms.
For question 4.A.3, you need to identify the method used to successfully locate housing. If the method used is not listed on the form, select “Other” and document the method used in the Notes section.
For question 4.A.5, you need to identify the type of residence to which the participant transitioned. If the type of housing is not listed, select “Other” and document the type of housing in the Notes section.
Section 5
In order to report accurate transition numbers for MFP, it is important that you complete 5.A.1 and 5.A.3 in Section 5 of the form.
For 5.A.1, you need to indicate whether or not the participant is enrolled in MFP.
For 5.A.3, you need to indicate the type of MFP qualified residence to which the participant transitioned. One of the options must be selected if the participant is enrolled in MFP.
Purpose of Data
You have already seen how the data collected in the NHT Outreach Form can be used to provide OLTL, NHT stakeholders, and NHT partners with information regarding barriers to transition and utilization of housing program resources.
There are additional ways in which the data from the NHT Outreach Form is used.
Program Justification
Data from the NHT Outreach Form can be used to provide program justification.
Successful transition numbers/totals are calculated and reported to CMS by OLTL.
These successful transition numbers validate the need for the NHT program.
Program Funding
When OLTL reports the number of participants that transitioned successfully from nursing facilities to the community AND were enrolled in MFP, Pennsylvania receives enhanced federal funding on community services.
Program Evaluation
In addition, data pulled from the NHT Outreach Form may be used to evaluate the NHT program and resources.
This includes the identification of areas for improvement and allocation of resources to create a more effective program.
Agency and Program Reports
Data from the NHT Outreach Form is used to report your agency’s successes as shown on your agency dashboard report.
In addition, data from the form is used for the NHT program and MFP reports.
Key Data Collection Questions Review Activity
Take a few moments to check your understanding of this section by completing these review questions.
1. Which of the following questions must be answered in order to report a successful transition of an individual from a nursing facility to the community? (Select all that apply.)
1.A.1 Enter the date the participant consented to transition into the community
2.A.2 Enter the date the participant was admitted to the nursing facility
3.A.4 Select "yes" the participant completed transition to the community
3.A.5 Document all barriers that prevented the consumer from transitioning to the community
3.A.6 Enter the date the participant completed transition into the community
Please pause.
All but question 3.A.5 (barriers that prevented transition) are correct. While 3.A.5 is an important question, it is NOT used to report successful transitions.
2. True or False? The data collected from the NHT Outreach Form is important because it provides program justification and funding.
Please pause.
The correct answer is True. Not only does the data collected from the form provide program justification and funding, it can also be used to evaluate the effectiveness of the program; to write agency, NHT, and MFP reports; to identify barriers to transition; and to evaluate the utilization of housing program resources.
NHT Outreach Form Module Summary
In this module, we explored the NHT Outreach Form, including:
- What type of information is collected
- When the form should be completed and by whom
- Why the information is collected
Congratulations!
Congratulations! You have completed the Nursing Home Transition Outreach Form training.
If you have read the contents of the entire module, go to to register your completion of this module.
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