Nursing Home Transitions

Our focus is to assist all clients that desire to thrive independently in community base living.

An Independent Living Specialist assists individuals interested in transitioning out of a nursing home by:

• Identifying needs and risks
• Providing information about community resources available
• Assisting with housing voucher application
• Assisting with the research for suitable housing
• Setting up extended transition services prior to discharge such as home care, transportation, and home delivery meals
• Coordinating facility discharge
• Monitoring consumers’ progress following discharge

A nursing home transition specialist is focused on providing guidance and assistance to persons in nursing homes and assisted living facilities to become independent and return to the community with supportive community services. The consumer decides on a transition team and a plan needing to complete a discharge plan is agreed upon. The plan usually requires involvement of community health and residential services of the consumer’s choice. Transition plans are always driven by the consumer. Housing suggestions are made to the consumer and in many instances public housing applications are submitted on their behalf. Medical consent to leave a facility is obtained and safety plans are created with the transition team. Housing is a major hurdle for persons wishing to transition. Most consumers have little or no family support and some prefer not to involve family members.

In 2020, 8 persons were able to transition through the assistance of the Center Toward Self Reliance team.