Meet Mary, a 72-year-old in the hospital recovering from an illness. Her doctor advises she will need long-term care when released.
Mary wants to live independently but understands she needs support to do so. As she talks with the hospital social worker about nursing home options, she’s also told about the TARCOG program called Hospital to Home that may be able to get her home with Medicaid Waiver services upon discharge from the hospital.
TARCOG’s Director of Aging Programs Sheila Dessau-Ivey said the 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.
“Once I get the referral it’s a fast-paced process to seek the approval and get everything in motion for the client,” Kelley said. “For many, it’s a great option that allows them to stay in their home with the required assistance.”
She said 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)
Kelley said there are two Medicaid waivers utilized for the Hospital to Home program.
The Alabama Community Transition (ACT) Waiver traditionally 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.
TARCOG’s Hospital to Home Program may be an option for some patients who require long-term care after hospitalization. Speak to a hospital social worker for a referral to the program.