The Take Me Home (TMH) Transition Program is a program of the West Virginia Bureau for Medical Services (BMS). The purpose of TMH is to identify qualifying residents of long-term care facilities who wish to return to their own homes and apartments in the community and provide them the supports and services they need to do so.
Qualifying for Take Me Home (TMH) Transition Program
The Take Me Home (TMH) Transition Program will accept referrals from (or on-behalf of) residents of long-term care facilities if:
- The resident currently resides in a qualifying institution (such as a nursing facility, hospital or an Institution for Mental Disease (IMD))
- The resident has, or wishes to transition to, a home or apartment in the community, and
- The resident is currently eligible, or likely eligible, for either the Aged and Disabled Waiver (ADW) or Traumatic Brain Injury Waiver (TBIW) program
- An Intake Interview by TMH Transition Coordinators is then conducted to gather additional information needed to make a determination of whether the resident qualifies to participate in the Program.
Services
Individuals wishing to transition to the community often face numerous obstacles. These may include a lack of funds for security and utility deposits, lack of basic household items and furniture, limited community support, and no one to help them develop a comprehensive plan to transition home. TMH helps address many of these barriers by providing services and supports to qualified applicants including:
- Transition coordination
- Pre-transition case management, and
- Community transition services
Transition coordination is the lynchpin of TMH. TMH transition coordinators work one-on-one with program participants and their transition teams to develop person-centered transition plans and facilitate delivery of necessary services to support TMH participants’ transition to the community.
Waiver pre-transition case management is available to ensure that direct-care services are in place day-one of the TMH participant’s return home.
Two types of Community Transition Services (CTS) are available:
The Waiver Community Transition service can cover many one-time expenses needed to establish a home in the community including:
- Home modifications
- Moving expenses
- Home furnishings
- Essential household items
- Rental security and utility deposits
To qualify for the Waiver transition services (Pre-Transition Case Management and Community Transition Service), individuals must:
- Live in a nursing facility, hospital, Institution for Mental Disease or a combination of any of the three for at least 60 consecutive days and
- Have been determined medically and financially eligible for either the Aged and Disabled Waiver (ADW) or Traumatic Brain Injury Waiver (TBIW) program, and
- Wish to transition from facility-based living to their own home or apartment in the community consistent with the Centers for Medicare and Medicaid Service (CMS) Settings Rule (1915(c)) and
- Have a home or apartment in the community to return to upon leaving the facility that is consistent with the CMS Settings Rule and
- Require Waiver transition services to safely and successfully transition to community living and
- Reasonably be expected to transition safely to the community within 180 days
The MFP Community Transition Service is a demonstration service funded through the Money Follows the Person grant that can provide:
- Assistive technology
- Specialized medical equipment and supplies
- Transportation
- Initial food supply (available after the Public health Emergency)
- Miscellaneous transition support services
There are also three additional MFP demonstration (grant funded) services available to support the transition of TMH participants:
- Home modification, which can be used in conjunction with the Waiver CTS
- COVID related services, which include pantry stocking, internet access fees and equipment (such as a tablet) to access the internet
- Personal Emergency Response System (PERS)