Question #1: Am I eligible to participate in the Take Me Home, West Virginia Program?
Answer: To be eligible to participate in Take Me Home, you 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”.
You must also qualify for and access one of the following Medicaid home and community-based service programs upon your return to the community:
- Aged and Disabled Waiver (ADW) Program;
- Traumatic Brain Injury (TBI) Waiver;
- State Plan Personal Care Program, or;
- Behavioral Health.
It’s also important to note that if you are eligible to participate in the Program, Take Me Home can support your transition to the community only if a plan can be developed to meet your long-term care needs and there is a reasonable expectation of a safe and successful transition to the community.
Question #2: What is a “qualified residence”?
Answer: A “qualified residence” is:
- A person’s own home;
- A person’s family home;
- A person’s own apartment, or;
- A group home with 4 or fewer people
Question #3: How do I apply for Take Me Home, West Virginia?
Answer: Applications to Take Me Home, West Virginia are made through a referral process. Anyone, including you, facility staff, or your family/friends can make a referral. All referrals must be made by contacting your local Aged and Disability Resource Network (ADRN). The ADRN staff will gather basic information including whether the applicant currently resides in a qualifying institution, qualifies for Medicaid, wishes to transition to a qualifying residence, etc. If you are determined likely eligible for Take Me Home based on this information, the ADRN staff will “pass” the referral to a Take Me Home Transition Navigator. The Transition Navigator will contact you to schedule an Intake Interview. Information collected in the Intake Interview is then submitted to the Take Me Home Office where a final determination of eligibility for Take Me Home participation is made. To make a referral to the Take Me Home, West Virginia Program please call 1(866)-987-2372.
Question #4: Who will help me transition home?
Answer: If you are determined eligible to participate in the Program, a Take Me Home Transition Navigator will be available to help support you every step of the way. The Transition Navigator will:
- Explain the Program and answer any questions you may have;
- Help you assess what you need to make a successful and safe transition from living in a facility to living in the community in your home or apartment;
- Develop a comprehensive Transition Plan outlining the services and supports you will need to successfully transition and live in the community;
- Co-ordinate the implementation of the Transition Plan by your transition team and;
- Help you “settle in” transition day, and;
- Follow-up with you for the first 365 days in the community to help identify and support additional needs or issues that may arise.
Your transition team should include key facility staff, community providers, and anyone you choose to participate in the planning of your transition home. This may include family members, friends or any other person you trust and want to be involved.
Question #5: In addition to the help of a Transition Navigator, what other benefits does Take Me Home offer?
Answer: The Take Me Home, West Virginia Program may cover many of the “one-time startup” purchases you need to return home. For example, the Program may help you with:
- Housing application fees;
- Moving expenses;
- The security deposit for your new apartment;
- First month’s rent;
- Essential household items such as needed furniture, kitchen appliances, pots and pans, etc.;
- Initial food supply, and;
- Minor home modifications such as the installation of grab bars, levered door handles, etc.
The Program may also be able to cover other “Goods & Services” such as assistive technology and more extensive home modifications such as installing ramps, accessible bathrooms, etc. Finally, depending on your needs for hands-on care, the Program may be able to provide more direct-care hours each month than is provided through the standard Aged & Disabled Waiver or Traumatic Brain Injury Waiver Programs.
Question #6: What services and supports can I receive after transitioning?
Answer: In addition to the Take Me Home services listed above, you will have access to all Medicaid home and community-based services when you return to the community for which you qualify. These may include:
- Aged and Disabled Waiver services (Case Management and Personal Assistance);
- Traumatic Brain Injury Waiver services (Case Management, Personal Attendant and Cognitive Rehabilitation Therapy);
- State Plan Personal Care services, (direct-care support), and;
- Behavioral Health services.
- Remember, the Transition Navigator will continue to support your transition for as long as 365 days in the
Question #7: Who will provide my services and supports once I return home?
Answer: You will have the opportunity to freely choose from a list of qualified home and community-based service agencies to provide your services. Since it is important to have all of your services in place your first day in the community, you will know who these agencies are before you ever leave the facility. If you enroll in either the Aged & Disabled Waiver or Traumatic Brain Injury Waiver Program, you will also have the opportunity to direct your own services by choosing the Self-Direction Model. This option allows you to select, hire and manage your own employees to provide your direct-care needs rather than using one of the provider agencies.
Question #8: I don't have a home to return to. Where will I live?
Answer: Your Transition Navigator and the Take Me Home Housing Coordinator will help you find a qualified residence if you need assistance in finding a place to live. They will work with you to determine if the apartment or house you’ve chosen meets your accessibility needs or, if needed, can be modified to meet your needs
Question #9: How will I get services and supports after day 365?
Answer: It is true that Take Me Home services will not be available to you after 365 days in the community. However, you will continue to receive all of the Medicaid home and community-based services for which you qualify. For example, if you qualified for Aged Disabled Waiver services when you transitioned home, you will continue to receive those services after 365 days in the community as long as you still meet the Waiver eligibility requirements.
Question #10: How long will it take to transition home?
Answer: The amount of time it takes to transition differs with every person and every situation. If you have a home to return to and strong family support, your transition may happen more quickly than someone who first has to find a new apartment or needs extensive modifications to their apartment or home to make it physically accessible. Locating accessible and affordable housing can sometimes be difficult and, depending on your preference for the location, may take several months.
Question #11: Who can I talk to if I feel my wishes are not being heard?
Answer: One of the primary responsibilities of the Transition Navigator is to ensure that your wishes, desires, goals and preferences are heard throughout the transition process. If you have a concern about not being heard, bring this to the attention of your Transition Navigator. In addition, the Take Me Home, West Virginia Program partners with the State’s Long-Term Care Ombudsman Program to facilitate communication and troubleshoot issues and concerns of Take Me Home participants. You can talk with the Regional Ombudsman any time you have a concern or a complaint. You can contact your ombudsman at 1-800-834-0598.
Question #12: What If I Have A Legal Guardian Or Other Representative?
Answer: Residents without the capacity to make medical decisions can participate in Take Me Home with the assistance and support of their legal representative. Transition services and supports, along with needed community-based services and supports, will vary from participant to participant and will be developed to ensure a successful and safe transition home. Each Take Me Home participant will also have a 24-hour Emergency Backup plan that will include a Personal Emergency Response System (PERS).