Emerging Principles

Quality Transitions in Long-Term Services and Supports (LTSS) Emerging Principles (A Working Draft)

Transitions within the long-term care community are defined by various populations, occur in various settings, and are facilitated by various people serving differing roles. And like any social-professional evolution, the core competencies essential for quality transition planning become more refined over time. Despite North Carolina’s diverse transition landscape, an emerging set of principles are helping shape how “quality” is defined in the transition process.

People who facilitate quality transition planning

  • Understand that at the center of every transition, is a person, whose interests, needs, personality and circumstances uniquely inform and shape the transition dynamic;
  • Support the person exploring a potential transition in making an informed decision about how, when and where to transition– facilitating opportunities to see and experience options if needed to feel truly comfortable in her ultimate decision, including not transitioning at all;
  • Enjoy the transition process and supporting a person’s access to community life—the hard work, the collaboration, the long to-do lists;
  • Serve as a knowledgeable guide to the person transitioning and as appropriate, to her family, understanding that the person will soon be making a significant life change and may be anxious about the process;
  • Model a respectful, positive, “can do” attitude throughout the process to both the person and all others helping with the transition;
  • Understand that an “assessment” of a person’s transition needs is deeper than simply reviewing records, but requires building a relationship with the person and others as appropriate to fully appreciate what capacities are present and what supports are needed.
  • Are “optimistically honest” about challenges the person transitioning may face, but sincerely works to overcome those challenges even if they may ultimately prove to be insurmountable;
  • See the person and, as appropriate, her family as central participants in the transition process, deserving regular communication and support and taking on responsibilities in the transition work and guiding the process where possible;
  • Understand, through conversation and research, why a person came to the facility and why they are motivated to transition home, using these reasons to guide and shape the transition planning;
  • Understand effective transition planning does not hinge on becoming the expert on all areas relevant to a transition but rather partnering with the experts to ensure a person’s needs are effectively supported;
  • Understanding that transition planning requires creative thinking and the curiosity to seek out solutions that are right for the person transitioning;
  • Are willing to be flexible to meet the specific transition needs of the person involved;
  • Assume responsibility for ensuring all of the necessary partners do their part and that identified services and supports are in place upon transition and begin as intended.
  • Are highly organized and responsive to the person and to the team members assisting in the transition.

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