Do I or my patient Qualify?
Nursing Home Transitions
A Nursing Home Transitions (NHT) program was developed to assist and empower individuals who wish to return to the community from a Nursing Home setting. The creation of the program was inspired by our recognition that eligible participants could be better served in their own communities and outside of institutional care settings for a more fulfilling life. This program is a natural extension of PCC’s mission while being cost-effective for community resources.
NHT assists qualified individuals in their efforts to return to their home and community by partnering them with a Care Manager who will provide the support to overcome any identified barriers. Some of these barriers may include a lack of familial support, housing (inclusive of security deposits, purchasing of furniture and other necessary household items), a need for waiver services in the community, assistance with accessing community services including mental health needs, public assistance and many other potential barriers to care.
PCC actively manages nearly 100 NHT participants currently. PCC will continue to invest and grow this program vital to the success of supporting at-risk participants’ independence in the community.
List of Services
Individuals enrolled into the NHT program will get an assigned care manager to assist them with their transition. Your dedicated care manager will be with you in every step from orientation through your discharge back into the community and set up of your home in the community. As your ally and advocate, the NHT care manager will help navigate through many barriers including the following:
- Providing transportation to and from property showings
- Acting as a liaison between the health plan, Social Worker, family, landlord/property management company, regional housing coordinator, and Independent Enrollment Broker or County Assistance Office when setting up services post-transition
- Assistance with the completion of paperwork
- Residency applications, applications for birth certificates, in-kind benefits from CAO, community resources like LogistiCare or credit counseling
- Financial setup and support of new home, which may include items such as security deposit and/or first month’s rent, household goods, groceries, or other resources.