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What Services Are Available?

Individuals wishing to transition from long-term care facilities to the community often face numerous obstacles including no money for rent and utility deposits, lack of basic household items and furniture, limited community supports, and no one to help develop effective transition plans.

When returning to the community, Take Me Home participants will receive supports from existing home and community-based service programs such as the Aged and Disabled Waiver (ADW), the Traumatic Brain Injury (TBI) Waiver, State Plan Personal Care Services, or the Supported Housing program of the Bureau for Behavioral Health and Health Facilities (BBHHF). In addition to the home and community-based services for which they qualify, participants of Take Me Home will also be eligible to receive the following Take Me Home services:

Transition Navigation
Take Me Home Transition Navigators are located statewide to assist participants in moving from the facility to the community.  The role of Transition Navigators is to …

  • Assess a participant’s need for services and supports,
  • Help develop individualized Transition Plans,
  • Oversee the delivery of needed services and supports, and
  • Support each participant for one year after they transition to their own home and community.

Community Transition Services
Community Transition Services are one-time services needed for the initial transition from a facility-based setting into the community. These services may include …

  • Moving expenses,
  • Security and utility deposits,
  • First month’s rent,
  • Essential and basic household furnishings, and
  • Home accessibility modifications necessary to improve independence and ensure safety.

Care Supports
Care Support provides Take Me Home participants options for Peer Support, Direct-care for Trial Visits, and Respite as well as the opportunity to "extend" their use of certain Medicaid Waiver and State Plan services for which they are eligible. This may include for example, more direct-care service per month than is currently available through the Medicaid home and community based Waiver programs.

Take Me Home Goods & Services
Goods and Services are equipment, services or supplies not otherwise provided by Medicaid that address an identified need in the Take Me Home participant’s Transition Plan. These goods and services can provide a wide range of support, including the purchase of assist technology that significantly enhances the opportunity for Take Me Home participants to live independently in the community.

Supported Housing
Supported Housing is independent housing in the community coupled with the provision of needed community mental health and support services. The Supported Housing service is available for Take Me Home participants transiting from an Institution for Mental Diseases (AIMED) with a diagnosis of serious mental illness, serious mental illness and co-occurring addiction, or serious mental illness and a co-occurring developmental disability.

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