Nursing Home Transition (NHT) Program
(Nursing Home Transition (NHT) Program for Providers Page)
The NHT Program was developed to assist and empower consumers who want to move from a nursing facility back to a home of their choice in the community. NHT also helps the Commonwealth rebalance its long-term living systems. When given choice, an overwhelming number of people say they want to age in place in their homes rather than in institutions. Yet, in publicly funded programs, the bias has always been toward institutional care. NHT provides the opportunity for individuals and their families or caregivers to be fully informed of all long-term services and supports options, including the full range of available home and community-based services (HCBS). Through the NHT program, individuals can receive the guidance and support they need to make informed choices about their long-term services and supports. The program assists individuals in moving out of institutions and eliminates barriers in service systems so that individuals receive services and supports in settings of their choice.
Goals and Objectives of the NHT Program
- Help rebalance the long-term living system in Pennsylvania so that people have a choice of where they live and receive services.
- Enhance opportunities for individuals to move to the community by identifying individuals who wish to return to the community.
- Identify and overcome barriers that prevent transitions.
- Empower individuals so they are involved to the extent possible in planning and directing their own transition from a nursing facility back to a home of their choice in the community.
- Develop the necessary infrastructure and supports in the community.
- Expand and strengthen collaboration between aging and disability organizations to provide support and expertise to the NHT Program.
- Educate individuals and families about long-term living services.
Home and Community-Based Services (HCBS)
Many people don't realize that they may be able to receive long-term care services and supports in a home in the community instead of in a nursing facility. The following is information about some of the programs that provide HCBS to qualified individuals.
Who to contact?
If you would like to apply for a Home and Community Based Services Medicaid Waiver, contact the Pennsylvania Independent Enrollment Broker (IEB) at: 1-877-550-4227.
You may also begin your application for benefits online using the COMPASS website.
If you need help but are not sure who to contact, there are several ways to access information and referral services:
If you or a loved one is interested in returning to the community from the nursing facility, you may initiate the nursing home transition process by:
- Contacting nursing facility staff to initiate a Nursing Home Transition (NHT) referral OR
- Contacting an available NHT Coordination Agency directly (applies to individuals who are not enrolled in Community HealthChoices). Locate your county using the following list to identify an NHT Coordination Agency to assist you in exploring the available options to transition home.
NHT Coordination Agencies
- Contacting your Community HealthChoices (CHC) Managed Care Organization (MCO) if you are enrolled in CHC
If you have any difficulty or need assistance in this process, you may contact the Office of Long Term Living Nursing Home Transition Helpline at 1 (800) 833-5196.
Additionally, there are many things you can do to prepare for the transition. The following are checklists developed by Nursing Home Transition providers, partners, or agencies which may be helpful for individuals in planning their transitions.
Preserving Existing Housing
If you still have appropriate housing to return to and expect to be able to be discharged from the nursing facility within 180 days, you may be eligible to set aside some of your income to use towards upkeep of your housing through the Home Maintenance Deduction. Eligibility for the Home Maintenance Deduction is determined by the County Assistance Office. The nursing facility social worker can assist you in the application process.
Sometimes existing housing is no longer safe or accessible. If you have a home but cannot return to it as-is due to a change in your condition, you may be able to get help with modifying or adapting your home to make it accessible. Many of the Home and Community Based Waivers include funding for home modifications.
Below are some links to additional information and resources related to home modifications, accessibility adaptations, and assistive technology:
Locating New Housing
If you do not already have appropriate housing but you wish to return to the community, one of the first steps to transition is to locate affordable, accessible housing. PAHousingSearch.com is a searchable database that can assist you in finding appropriate housing.
You may also find useful information at the Pennsylvania Housing and Finance Agency (PHFA) website.
In order to complete applications for housing and/or benefits, you may need to provide documents verifying certain important information. Below is a list of commonly required documentation. Included in the list below, where available, are hyperlinks to sites where you can request copies of documentation.
- Proof of earned and unearned income
- Proof of resources, e.g. bank accounts, stocks, etc.
- Proof of identity:
Each nursing facility must provide access to an ombudsman who is not employed by the nursing facility and is available to help if you have a complaint or concern about the long term care services you are receiving.
OTHER RESOURCES AND CONTACTS