Transition Coordination

The transition process requires the collaboration and coordination of many “moving parts” focused on meeting the individual needs, desires, and goals of the Take Me Home participant; all of which must fall into place on or immediately before transition day. TMH Transition Coordinators:

  • Work one-on-one with residents and their Transition Teams;
  • Accept and follow-up with referrals from the Aging & Disability Resource Network (ADRN);
  • Conduct face-to-face interviews with applicants to share information about options for returning to the community, including the availability of Waiver transition services;
  • Assess the resident’s readiness to begin the transition assessment and planning process;
  • Assess the resident’s transition support needs, including risk factors that may jeopardize a safe and successful transition to the community;
  • Facilitate the development of a Transition Team consisting of the resident, the Transition Coordinator, the Waiver case manager (A case manager is required for the Traumatic  Brain Injury Waiver (TBIW), a participant on the Aged and Disable Waiver (ADW) may choose to have a case manager or not), the resource consultant (for residents planning to self-direct their Waiver services), the Ombudsman (if applicable), the facility social worker and other appropriate staff and anyone else the resident chooses to include in the transition process;
  • Work with the resident and his/her Transition Team to develop a written Transition Plan which incorporates specific services and supports to meet identified transition needs (which may or may not become part of the Waiver Service Plan);
  • Conduct a Risk Analysis and develop a written Risk Mitigation Plan to address and monitor all identified risks that may jeopardize the resident’s successful transition, (which will become part of the Waiver Service Plan) and;
  • Arrange and facilitate the procurement and delivery of needed services and supports including, but not limited to, Waiver transition services prior to transition.;
  • Conduct outreach and serve as a liaison with nursing facilities to foster effective communication with facility staff and troubleshoot any issues that may create barriers to a safe and successful transition, and;
  • Work with the case manager and/or resource consultant on any identified needs post transition.


Transition Coordinator​ Procedures and Forms

Transition Coordination Procedures Manual

Intake Form
Transition Assessment Tool
Transition Planning Tool
Transition Assessment and Planning Readiness Verification
Risk Analysis and Mitigation Tool
24 Hour Emergency Backup Plan

Current Transition Coordinators:
Transition Coordinator Name
Contact Information
Counties Covered
Paula Corley
Hancock, Brooke, Ohio, Marshall, Wetzel, Monongalia, Marion, Preston
Josh Phillips
Jefferson, Berkley, Morgan, Hampshire, Mineral, Grant, Hardy, Pendleton
Autumn Hager
Tyler, Doddridge, Harrison, Barbour, Tucker, Randolph, Upshur, Lewis, Doddridge, Ritchie, Pleasants, Wood, Wirt, Calhoun, Gilmer, Braxton, Webster, Roane, Jackson
Gina Fisher
Mason, Putnam, Kanawha, Clay, Boone, Lincoln, Cabell, Wayne, Mingo, Logan
Sam Ball
Nicholas, Pocahontas, Greenbrier, Fayette, Raleigh, Summers, Monroe, Wyoming, Mercer, McDowell
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