Getting Home, Staying Home
Care Transitions is a free, short term service for adults who currently reside in a rehabilitation or nursing facility and whose goal it is to return to the community. The Care Transitions Team can meet with individuals and their caregivers via phone, email, virtual, in person, or a combination.
The Care Transitions Team can:
Provide Options Counseling to individuals and their caregivers by reviewing the landscape of services and public benefits for which they may be eligible
Work with individuals, their caregivers, and nursing facility staff to establish a safe discharge plan
Assess individuals for the state home care program if requested by the individual. Eligibility: age 60 and under with a diagnosis of dementia and older adults age 60+
Assist with making referrals to needed services and resources to ensure a safe discharge home
Meet with individuals in their home post discharge and assist with any needed follow up