Who Qualifies for TMH?The Take Me Home (TMH) Transition Program is a program of the West Virginia Bureau for Medical Services (BMS). TMH works with qualifying residents of long-term care facilities (such as nursing homes and hospitals) who wish to return to their own homes and apartments in the community, providing them the services and support they need to do so.
The TMH Program accepts referrals from (or on-behalf of) residents of long-term care facilities and patients of hospitals if:
- They currently reside in a qualifying institution (such as a nursing facility, hospital or an Institution for Mental Disease (IMD)
- They have, or wish to transition to, a home or apartment in the community; and
- They are currently eligible, or likely eligible, for either the Aged and Disabled Waiver (ADW) or Traumatic Brain Injury Waiver (TBIW) program
While the TMH Transition Program can begin working with individuals toward planning their transition to the community as soon as they are referred, transitions can not be supported by TMH unless:
- The TMH participant has resided in a nursing facility, hospital or IMD (or a combination of any of the three) for at least 60 consecutive days prior to the transition.
- The TMH participant has enrolled in either the ADW or TBIW program prior to transitioning home; and
- There is a reasonable expectation that the TMH participant can transition safely and successfully to the community.
What Services Does TMH Provide?
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 transition home. TMH helps address many of these barriers by providing services and support to qualified applicants including:
- Transition Coordination - 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 - Available to ensure that direct-care services are in place day-one of the TMH participant’s return home.
- Waiver Community Transition Service - Services necessary to establish a home in the community:
- Home modifications
- Moving expenses
- Home furnishings
- Essential household items
- Rental security and utility deposits
Note: To qualify for the Waiver transition services (pre-transition case management and community transition services), 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; and
- Have a home or apartment in the community to return to upon leaving the facility that is consistent with the Centers for Medicare and Medicaid Services (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
In addition to the Waiver transition services listed above, the TMH Transition Program offers numerous Money Follows the Person grant-funded services that address barriers TMH participants may face in transitioning to the community including:
MFP Community Transition Services:
- Assistive technology
- Specialized medical equipment and supplies
- Transportation
- Initial food supply
- Miscellaneous transition support services
Non-Routine Maintenance is the initial non-regular maintenance of the TMH participant's home that is necessary to ensure independence and health and safety. Services may include, but are not limited to:
- Mold remediation
- Debris and leaf removal from yard, sidewalks, ramps gutters and downspouts
- Snow and ice removal from porches, ramps, and sidewalks
- Mending of gaps and cracks in sidewalk and driveways to eliminate tripping hazards.
Home Modifications are modifications or adaptations necessary to increase independence and/or ensure health and safety in the home. Modifications may include, but are not limited to:
- Ramps
- Grab-bars
- Door widening
- Accessible bathroom features
- Initial Food Supply are essential food supply items to ensure adequate and necessary access to food and goods immediately following transition home. Environmental Control Devices: Any piece of equipment that allows an individual with functional limitations to control aspects of their environment such as lights, TV, telephone, door locks and cameras.
- Vehicle Adaptation are modifications or adaptations to accommodate special needs of TMH participants to allow access and/or use of a vehicle owned by the participant or the participant’s family member.
- Home Repair are repairs required to ensure health and safety of the TMH participant and are limited to those necessary to eliminate code violations and health & safety concerns and will only be made on a home owned by the participant or the participant’s family where the participant resides.
- Past Due Utilities covers past due utility bills (up to 6 months) owed by the TMH participant that present a barrier to transitioning to the community. Housing application and associated fees: Covers various expenses related to the rental application process such as credit checks, background checks, administrative fees, etc.
- Legal Support Services covers legal advice and consultation to address tenancy issues such as addressing potential barriers to securing and retaining appropriate housing. Also includes mediation of owner/tenant disputes post-transition necessary to retain housing.
- Clothing Allowance is clothing to address functional needs such as slip on shoes, clothing with Velcro laces and/or fasteners, etc. Also includes clothing to address significant weight gain or loss while living in the facility.