A Program to Help Nursing Home Residents Transition to the Community
Homeward Bound, Maine's Money Follows the Person program is a demonstration project funded by the Centers for Medicare & Medicaid Services (CMS) created to assist residents of nursing homes to return to the community. The project also hopes to identify how best to help people transition back to the community and to improve Maine's long-term care system. The Ombudsman Program is the Referral and Advocacy Manager for each person who enrolls in the program.
To be eligible, individuals must be 18 or older, have resided in a nursing home or hospital for 90 days by time of discharge, received MaineCare for at least one day in this setting and qualify for nursing home level of care in the community.
Homeward Bound will assist in creating an individualized transition plan. A Transition Coordinator, chosen by the participant, will work with the participant to identify the team. The team will work together to understand the participant's needs and create a plan for a transition back to the community.
Homeward Bound participants will receive support in accessing home and community based services as well as demonstration services including specialized clinical assessments, independent living assistance, household start-up, enhanced care coordination, technology services and more.
After the transition home, a Community Coordinator (usually the Transition Coordinator) will monitor the plan and address any needs and work with the team to resolve any issues.
Homeward Bound will assist with the transition planning and monitoring for the first year after the transition home. Any home care services will continue after the year has finished, but other services like the enhanced care coordination will end. The goal is that the services will be set up to meet the individual’s needs even when Homeward Bound has ended.
The Ombudsman Program’s role as advocates for long-term care consumers including those residing in nursing homes, residential care homes and assisted living and for those receiving home care services make our participation in Homeward Bound a natural fit for the program and will benefit the Homeward Bound participants.
For more information about Homeward Bound or to make a referral please contact us or call us at (800)499-0229. You can also contact Frances Ryan, Homeward Bound Program Director, Office of Aging & Disability Services, Maine Department of Health & Human Services, 41 Anthony Ave. SHS #11, Augusta, ME 04330 (207)287-9233.
If you would like to learn more about Homeward Bound from a participant’s perspective, please watch Homeward Bound - Cindy’s Story found here http://youtu.be/vOQp5RpgVTc.