Coming Home: One Story About Transitioning Out of Nursing Home Care

As a Transition Coordinator for Empowerline’s Community Transitions (formerly Money Follows the Person) program, I recently had the opportunity to work with a person who exhibited determination like this. Community Transitions is a federally funded Medicaid program, administered by over 40 states.

“Maggie” (name changed to protect her identity) had been living in a nursing home for several months following a hospitalization, but she knew she was ready to leave. She no longer needed the health and personal care services provided there, and she wanted to live life independently. So, in 2016, she applied to the Money Follows the Person program (today called Community Transitions), which transitions eligible people from long-term care facilities back into community settings.

That’s when she faced her first speedbump. Her leads for housing fell through again and again. In addition to that, she’d experienced problems in the past with housing credit, but she was determined to realize her dream of returning to the community. Maggie lacked much family support to help her find housing or to give her a place to live while she transitioned to independence, and the Social Services Department at her nursing home couldn’t help her either.

But she didn’t give up.

We advised her to place her name on several senior housing waitlists and to let us know when she had found housing. And we did hear from her. Maggie was maybe our only client ever to phone in regularly, “just to keep in touch and let you know that I’m still here,” she would say.

Two years passed this way. Finally, her moment came. With her credit issue resolved, Maggie was called by a HUD-subsidized senior independent living complex where she’d been on the waitlist.

There was one catch: there was a deadline to move her in, and it was swiftly approaching. The Community Transitions Team sprang into action.

When Transition Day arrived on September 27, 2018, Maggie moved into her new home. Empowerline’s Community Transitions program coordinated and provided:

  • Payment of Maggie’s security deposit and first month’s rent to make moving more affordable
  • Transportation from the nursing home to her new home
  • Purchase of furniture and household goods
  • Purchase of durable medical equipment that Medicaid would not cover
  • Peer supporters (people with a disability themselves who meet with others and help them understand how to get around in the community with their disability) to assist with her readjustment to the community
  • New dentures
  • CCSP (Community Care Services Program) Medicaid Waiver to provide case management and personal support services (i.e., aide in the home three days per week)
  • Visiting physician’s service on a monthly basis
  • Computer tablet recommended by peer supporters to connect her with the community and to improve socialization

The program works by coordinating the delivery of critical needs, such as durable medical equipment, assistive technology, home care services, and furniture, as well as other home and community-based services to ensure a safe and successful transition back to the community. It does all this by serving as a “redistribution” of Medicaid dollars from skilled nursing facilities to the community, indicating that Medicaid dollars may “follow the person” back to the communityLiving Room Couch with Side Table with better outcomes.

Dale Carnegie once said, “Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.” This was certainly true of Maggie. It was a pleasure working with someone who never lost sight of her dream to return to the community and to live her life to the fullest.


If you or a loved one are currently considering a move, Empowerline is here to help. Our counselors can help you understand what long-term service options are available and how the cost of those services are covered. You can also learn more about your housing options on Empowerline.

Sandra Kirton

Sandra Kirton works in the Aging and Independence Services Group as a Transition Coordinator with the Community Transitions nursing home transition program. Sandra has worked with this program for the past six years with an amazing team that makes miracles happen every day.