How Can I Bring My Loved One Home from a Nursing Home?

Are They Eligible for Medi-Cal? Look into our California Community Transitions Program

What Services Are Provided?

Senior woman using walker

  • Transition assistance from an in-patient facility back into the community
  • Home set up (includes furniture)
  • Home and vehicle adaptation
  • Assistive devices, wheelchairs and other medical equipment
  • Training on self care and how to get a personal care attendant
  • Transition coordination by a nurse and social worker

Who pays for these services?

  • Medi-Cal covers all allowable expenses of the transition process
  • Paid for through a federally funded grant—Money Follows the Person
  • Funding is not affected by the Affordable Care Act

What are the eligibility requirements?

  • Individual must be in a skilled in-patient facility for 90 days
  • Medi-Cal must pay for one full day in the facility
  • Individual must agree to become a part of the program following assessments

How is the transition process carried out?

  • Transition coordinator provides initial assessment to learn about individual’s needs
  • Second assessment given approximately two weeks after initial assessment
  • Comprehensive Service Plan (CSP) is developed
    • Team project involving the individual, Transition Coordinator, Nursing Facility Staff, Physician, and other Service Personnel to be involved in providing services to meet the individual’s needs
  • Home environment is established
  • CSP supportive services are put into place
  • Quality of Life (QOL) Survey completed around the time of transition
  • Referrals made for long term supportive services to keep individual safe in the community
  • Second QOL completed eleven months after transition
  • Third QOL completed twenty-four months after transition
  • Transition coordinators stay in contact with the individual 1 year after transition

Have more questions? Call us at 1-800-400-0727 or 530-343-0727 or visit our website.

Picture of Katy Deaton, Director of Communications


Katy Deaton, Director of Communications
Home & Health Care Management
“Keeping your loved ones safe, healthy, and independent!”

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