Nursing Home Transitions

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The Community Transitions Service is a program that provides helps eligible nursing home facility residents transition from living in the nursing home.

The program is available to residents of nursing facilities who are currently on Medicaid, or Medicaid eligible* with a barrier to returning home. Some barriers people might face include:

      • Losing the home or apartment they were living in before entering the nursing home
      • Needing ongoing care services at home
      • Their home is not barrier free and accessible
      • They need durable medical equipment at home (Things like hospital beds, patient lifts, or wheelchairs)
  • Their current home needs special attention due to allergens, pests or extensive clutter

Counselors from the program work with people one-on-one to address those barriers and help them find a living situation that is safe and will work for them.  Counselors visit people right in the nursing home and get to know their needs  then work with them and their nursing home discharge planners to put together a plan to transition them out.

There are lots of options. People can move back to their own homes, move in with family members, or move into an apartment, an assisted living facility or an adult foster care facility.

In addition to the help finding the right housing situation, the program also helps people put together the care and support services they will need to live successfully once they are home. Efforts will be made to identify community resources to address the individual’s needs, and ongoing services may be available for those who meet functional and financial guidelines.

Nursing facility residents may request transition services for themselves, or a referral for services may be made by any concerned individual such as a family member, friend or social worker.

If you’d like to find out more, or see if you or a loved one might be eligible for the program, call the Area Agency on Aging 1-B Information and Assistance Line at (800) 852-7795 Monday through Friday from 8 a.m to 5 p.m. You can also fill out the online form below to have someone contact you.

*Current Medicaid financial guidelines are $2199 monthly income for an individual (a spouse income in not computed) and assets of $2,000 or less  (federal spousal impoverishment guidelines applied when considering assets.)

Note: Services provided are paid for by the Michigan Department of Community Health and the Centers for Medicare and Medicaid Services.

To Receive a Call Back from a Specialist About the Program, Fill Out the Form Below:


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