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Let’s talk about: Hospital to Home

March 24, 2025

If you find yourself hospitalized and learn you will need long-term care, TARCOG has a program that may be able to you get home with Medicaid Waiver services instantly upon discharge.

TARCOG’s Medicaid Waiver Program Manager Melissa Brinkley says the appropriately named “Hospital to Home” program starts with a referral. Hospital social workers, discharge planners, or social services case managers work with a patient to take the first step toward a safe transition.

Hospital to Home uses an expedited application process to initiate services immediately, she said.

Kelley Carpenter is TARCOG’s Hospital to Home Transition Coordinator. If a referral is made, she goes to the hospital to meet with the patient to determine eligibility and begin the transition process.

To qualify for Hospital to Home transitional assistance a patient must meet the following requirements:

  • Must have a Medicaid eligible status
  • Must be medically eligible for long-term care
  • Must have a safe and suitable home to return to
  • May be required to have a willing and able caregiver

Based on the care plan development a person may be able to get assistance with the following:

  • Homemaker services like housekeeping, laundry, grocery shopping, and errands
  • Personal care services like bathing, dressing, and grooming assistance
  • Weekly home-delivered meals
  • Medical supplies such as incontinence supplies, wipes, and linen savers
  • A Personal Emergency Response System (PERS)

Melissa said there are two Medicaid waivers utilized for the Hospital to Home program.

The Alabama Community Transition (ACT) Waiver traditional serves people with disabilities or long-term care illnesses who currently reside in an institution and who desire to transition to the home or community setting.

There’s also the Elderly and Disabled (E&D) Waiver which serves Individuals who are elderly and/or disabled. This is for a person who could live independently (or alone) at home with some additional assistance provided by the waiver.

Melissa said these waivers offer a consumer directed option which will give individuals the opportunity to have greater involvement, control, and choice in identifying, assisting, and managing long term services and supports.

Anyone interested in the Hospital to Home program should contact their hospital social worker, discharge planner, or social services case manager to have a referral made on your behalf. For more information, contact TARCOG at 256-830-0818.

Kelley Carpenter is TARCOG’s Hospital to Home Transition Coordinator.