Nursing Facility Transition:
The Nursing Facility Transition (NFT) helps those currently living in a nursing home move into a house, apartment, or assisted living and helps put necessary services in place.
Individuals work with a Transition Specialist who will explain the process and conduct an assessment to determine what services would be needed in order to transition out of the nursing home. They will then work together to develop a plan centered around the individual’s needs and choices (if desired, family and friends may also be included in the process).
Each situation and plan of care is individualized but examples of services provide include bathing, dressing, home delivered meals, assistance with medication and housekeeping.
- Residing in a nursing facility
- Currently on, or eligible for, Medicaid
- Desire to return to the community (house, apartment or assisted living)
- Has barriers to living independently such as needing in-home care and/or housing
- Live in our region (Allegan, Ionia, Kent, Lake, Mason, Mecosta, Montcalm, Newaygo and Osceola county-for a list of resources outside of our region, click here. For nationwide resources, click here.
To participate in the NFT program, a referral must be made to AAAWM (referrals can be made by medical professionals, family members, friends or the individual themselves).
To Make a Referral:
Please note, we are able to provide language translation services over the phone.
Contact our Information and Assistance team at (888) 456-5664 or (616) 456-5664 or click here to send an email (please note that our Information and Assistance team may need to contact somone by phone for additional information).
What information is needed for a referral to the NFT Program?
The following questions will be asked to determine if someone qualifies for the Care Management program. If they do qualify, an in-home assessment will also be done to determine what services are needed.
- Date of Birth
- Phone Number
- Marital Status
- Gross, monthly income amount
- Income source(s)
- Medicare number (if applicable)
- Medicaid number (if applicable)
- Preferred language
- Preferred contact person and relationship
- Description of care needs, including:
- Primary medical diagnoses
- Description of your ability to take care of daily needs (i.e. personal care, meals, housekeeping, and medication management).
- Assistance received from family members, friends, or other support persons (if applicable).
- Assistance received from another program (i.e. Mental Health, Adult Home Help, Skilled Nursing, private duty care, etc.)
- Questions Regarding the Nursing Facility
- Name of the nursing facility
- Social Worker name and contact information
- Admission date
- Discharge goal (location, time frame)
- Current care needs
- Barriers relating to discharge planning