Eligibility and Services

Who's Eligible to Participate?
To be eligible to participate in Take Me Home, West Virginia, individuals must:

  • Live in a nursing facility, hospital, institution for mental disease or a combination of any of the three for at least 90 consecutive days (excluding Medicare rehabilitation days), and;
  • Be eligible to receive Medicaid benefits on the last day prior to transitioning from the long-term care facility to the community, and;
  • Choose to move to a "qualified residence".

The individual must also qualify for and access one of the following Medicaid home and community-based service programs upon the individuals return to the community:

  • Aged and Disabled Waiver (ADW) Program;
  • Traumatic Brain Injury Waiver (TBIW);
  • State Plan Personal Care Program, or;
  • Community-Based Behavioral Health Services.

It's also important to note that if the individual is eligible to participate in the Program, Take Me Home can support the individual's transition to the community only if a plan can be developed to meet the individual's long-term care needs and there is a reasonable expectation of a safe and successful transition to the community.

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 Waiver (TBIW), State Plan Personal Care Services, or community-based behavioral health system. 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.


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