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At Home Evolutions, we like to inform our readers of other aging-in-place related services that can assist you. One such program is Pennsylvania’s Nursing Home Transition Program. Since the summer of 2006, the Pennsylvania’s Nursing Home Transition Program has offered seniors and people with disabilities who are currently living in a nursing facility the alternative to live at home with the assistance of home- and community- based support services. This allows seniors to age in place in the comfort of their own home.

The project was implemented by the Pennsylvania Departments of Aging, Health, and Public Welfare in collaboration with the Governor’s Office of Health Care Reform, local county assistance offices, local centers for independent living, home and community-based providers, and organizations representing nursing facilities.

The “enhanced” version of the program brings coordination of transition services for seniors 60 years of age or older into local Area Agencies on Aging, like the Butler County Area Agency on Aging (BCAAoA). In the past two years, nearly 100 Butler County seniors have been transitioned from a nursing facility back into their home. To transition back home, participants begin receiving personal care services, and may have some home modifications completed such as having a ramp and handrails installed to make it easier to get around the house.

“The Nursing Home Transition program was set up to help people have a choice in where their long-term care will be carried out,” explains Karen Ward, Nursing Home Transitions Counselor for the BCAAoA. “If they prefer not to stay in a nursing home, then the Nursing Home Transition program can help them overcome barriers or obstacles that are otherwise keeping them in a nursing home.”

Some of those barriers or obstacles could be overcome by installing ramps, stair glides, hand railings, remodeling the bathroom to accommodate wheelchairs.

Karen says that sometimes it’s just being able to provide services like having someone come in and give the family a break.

“In some of our extreme cases, we have to find housing for the person and get all of the bedding, clothing, furniture, food and everything for them to be set up in an apartment,” she adds. “It can be as little as information that the family or senior doesn’t have. For instance, we had some gentleman who was put on dialysis and didn’t have transportation to get him to his dialysis unit once he was discharged from the hospital. After some investigating, we discovered that his insurance would cover transportation to his dialysis unit. So he was able to transition home because he had transportation to meet his medical needs.

According to Leslie Boyle, Supervisor of the Assessment Program for the BCAAoA, sometimes the family themselves can be a barrier because they may not want to do this.

“But in talking with them, we help them understand a little more about Nursing Home Transition and what we can do for them,” she says. “Then they are less resistant and we can work out trying to get that senior home.”

The Enhanced Nursing Home Transition Program (ENHT) allows for a seamless transition for seniors from a skilled facility to home with BCAAoA services. Seniors under 60 years of age are served by this program in collaboration with local Independent-living Agencies.

A key component of the ENHT is Long-Term Living Counseling for seniors who are residing in a skilled facility. According to Leslie, many people are still not aware of the services available to them or whom to contact in their community to receive help.

“The goal of the program is to educate seniors and their families about available living options and how to access services and support,” she explains.

As a counselor, one of Karen’s duties is to speak to seniors and families in the community about ENHT.

“I talk to them about what their options may be and identify what barriers are keeping them inside a nursing home and how we can overcome that barrier,” she says.

Karen stresses that the program is available only to those who are currently in a nursing home.

“It would have to be someone who would most likely stay in a nursing home long term if we didn’t get involved,” she says. “My job is to identify these people and try to discuss and figure out what the barriers might be, then do an initial assessment and determine level of care.”

After determining the level of care, the case is sent over to the Care Management Unit within the AAA where a care manager will then go out and talk to the senior about specific services, needs or modifications that would allow him to transition back into his home.

There are two funding sources available for those seniors who need assistance in helping with any expenses that may incur.

“The first is under the waiver program, which is a program for medical assistance eligible people,” explains Karen. “They have to be medically nursing home eligible and financially eligible for medical assistance. The waiver program would pay for all of those services. If they are not waiver eligible, then there is a small pool of money through the Nursing Home Transition program funding that we can use for transition needs.”

To qualify for the ENHT, the person must be:

  • Age 60 or older
  • Age 18 or older with a physical disability that is expected to last for at least 12 months
  • Able to either independently or with support: direct their care, and handle their financial and legal matters.

There is plenty of help available in the community for those who want to live independently. Services available may include but are not limited to:

  • Adult Day Services
  • Advocacy
  • Affordable Housing
  • Assistance Finding or Accessing Social and Recreational Opportunities
  • Equipment Not Available Through Health Insurance
  • Home Delivered Meals
  • Home Modifications
  • Information and Referral
  • Peer Support and Skills Training
  • Personal Assistant Services
  • Personal Emergency Response Systems
  • Respite for Caregivers
  • Transportation

For more information, please call the Butler County Area Agency on Aging at 724-282-3008.

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