Nursing Home Transition is a program that assists individuals to transition from Nursing Homes back in to the community.
The only criteria for referring someone to the Nursing Home Transition program is that the individual is in a nursing facility and wants to return to the community. The protocol differs from a regular discharge plan because there are barriers identified that need to be overcome in order for the individual to go home.
Living in the community with supports allows people to remain in better health and thus reduce the costs incurred to care for them. We are working to enable and empower older adults instead of just caring for them.
For example, an individual may need a place to live. Housing options may need to be explored. Furniture, household supplies, security deposit, or services may be needed to get started upon discharge. Without the help of the Nursing Home Transition coordination the discharge may not happen.
If you are interested in finding out more about Nursing Home Transition, contact your Managed Care Organization (MCO).