Community Transition Services

The Community Transition Services helps those currently living in a facility move back into their own home, the home of a loved one or supportive living. Individuals work with a Transition Navigator who will explain the process and conduct an assessment to determine what services would be needed in order to transition out of the facility. 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 facility
  • Currently on, or eligible for, Medicaid
  • Desire to return to the community (own home, home of a loved one, or supportive living)
  • Has barriers to living independently such as needing in-home care and/or housing
  • Live in Allegan, Ionia, Kent, Lake, Mason, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, Osceola, or Ottawa County.

Referral Process:

To participate in the Community Transition Services program, a referral must be made to AAAWM (referrals can be made by medical professionals, family members, friends or the individual themselves). Contact Us to make a referral.