Community Transition Services
Helping you return home safely from a nursing facility
Returning home is possible with the right plan and support. We help you and your family plan, coordinate, and complete a safe, successful transition back into your home.
Transition back home with confidence
It's possible to return home—and we can help
For many individuals living in a nursing facility, it may not be clear that returning home and regaining independence is possible. But making that transition can feel overwhelming without the right support in place.
A&D Home Health Care’s Community Transition Services help make that move possible. We work with individuals, families, and care teams to plan, coordinate, and support a safe and successful transition from a nursing facility back into the home.
From coordinating services to preparing the home environment, our team helps ensure everything is in place—so you or your loved one can return home with confidence, comfort, and peace of mind.
Eligibility
Who is eligible for Community Transition Services?
Eligibility requirements can vary depending on the program and individual needs. Our team will work with you to determine eligibility, explain your options, and guide you through the process.
Community Transition Services are typically available to individuals who:
- Currently reside in a nursing facility or long-term care setting
- Express a desire to return to their home or community
- Are eligible for Medicaid or waiver-based programs
- Can safely live at home with the right combination of support services
If you’re interested in transitioning back home from a nursing care facility, we can help. Get in touch to check eligibility.
Support that lasts
Support that goes beyond the transition
The transition home is just the beginning. Our team continues to provide support after the move to ensure everything is working as it should.
We help monitor progress, address challenges, and make adjustments as needed. This ongoing involvement helps prevent complications, reduce hospital readmissions, and provide peace of mind for both individuals and their families. With the right support in place, returning home can lead to greater independence, improved quality of life, and a renewed sense of comfort.
A coordinated plan
Services that support a successful transition
Returning home involves more than leaving a facility—it requires careful planning and the right support system.
In-Home Care
- Skilled nursing services
- Therapy services as needed
- Meal preparation and homemaking
- Assistance with daily routines
Home Preparation
- Preparing the home for a safe return
- Coordinating medical equipment & supplies
- Identifying and addressing safety concerns
Transportation & Community Access
- Transportation to medical appointments
- Help accessing community resources and services
Care Coordination
- Ongoing communication with providers
- Coordination across multiple providers
- Monitoring and adjusting care as needs change
Frequently asked questions about Community Transition Services
How soon can I transition back home?
The timeline depends on how quickly we can coordinate services and necessary support. Some supports can be arranged fairly quickly, while others may take more time based on provider availability and individual needs. Our team works to get everything in place as efficiently as possible while ensuring care is safe, appropriate, and well-coordinated.
Do I need a referral from a doctor?
You don’t necessarily need a referral to return home. However, medical information is typically required during the eligibility process.
Does insurance cover these services?
Medicare, Medicaid, and private insurance may cover services needed to help you move back home—including nursing services, chores and transportation, meal preparation, accessibility changes, and more.
What does the transition process involve?
Transitioning home involves careful planning and coordination. Our team works with you, your family, and your care providers to create a plan that includes services, equipment, and home preparations.
What if my needs change after I return home?
It’s common for needs to change over time. Our team continues to monitor your situation after the transition and can adjust services as needed, so you continue to receive the right level of support to remain safe and comfortable at home.
Our service area
Community Transition Services across Michigan
A&D Home Health Care provides Community Transition Services across multiple communities in Mid-Michigan, the Saginaw Valley, and the Thumb. We work closely with local providers and resources to ensure a smooth and coordinated transition back to your home.
Start your transition back home
Returning home is possible with the right plan and support. A&D Home Health Care is here to help you navigate the process, coordinate your care, and ensure a safe and successful transition.