top of page

Community
Transitions

Heart in Hand

We believe people faced with decisions about long-term care should know their options.

You may be eligible for our services if you are:

  • Living in a nursing facility, in a hospital, or at risk of being placed in a nursing facility (diversion).

  • There are no other options or agencies to help.

  • Wanting to live in the community.

  • Experiencing barriers to moving out and into the community.

  • Receiving enough income to support yourself in the community.

Outline of house with door and window, Transitions Icon

Process

Referrals can be made by you (the resident), family members, friends, nursing facilities or hospital staff.

  • Interview

An interview will be set up with you (the resident), and any other persons involved that you wish.

  • Person Centered Plan

A Person Centered Plan will be conducted during the beginning stages of this process.  It is very important for the individual to be actively involved. The Person Centered Plan outlines your decisions about what is important to you as you make the transition from nursing facility or hospital to your home or independent living.

  • Support Services

Will provide assistance in locating the necessary supports and services to ensure a successful transition.

  • Discuss Barriers

The individual may terminate this process at any time if he/she chooses to remain in the nursing facility or hospital.

Possible Solutions

Every situation is assessed individually. Services are provided as funding is available.

  • Adaptive Equipment

  • Advocacy Support

  • Durable Medical Equipment

  • Emergency Caller Unit

  • Household Items

  • Guardian Information

  • Independent Living Skill Development

  • Lift Chair

  • Peer Support

  • Person Centered Planning

  • Ramp or Low Rise Steps, Safety Equipment/Grab Bars(with homeowner approval)

  • Resource Library Information

  • Temporary In Home Care

  • Smoke & Carbon Monoxide Detectors

  • Community Information

  • Therapeutic Leave Options/Trial Runs

For more information:

Carmon Yeloushan

CHW-Transition Navigator

Main: 517-782-6054

Direct: 517-998-3080

bottom of page