Community Transitions

Watch how to sign ‘transition’ in American Sign Language

Watch how to sign ‘home’ in American Sign Language

DMC Community Transitions Team L-R: Marisol Johnson (holding moving box) and Lizeth Arroyo (with DME chair) on ramp outside DMC.

Community Transitions Program

The Dayle McIntosh Center (DMC) believes people with disabilities and older adults should have equal opportunities to lead their lives as they choose. Gaining this independence is behind the purpose of the Community Transitions program, which is to assist individuals, who are in skilled nursing facilities to move back into the community.

What is a Skilled Nursing facility?

DMC Consumer Martha entering van with flowers via vehicle ramp lift to go home.

Skilled nursing facilities have different names but are defined as facilities that provide 24-hour skilled nursing care, as well as related and rehabilitative services to people that are chronically ill or recuperating from an illness or surgery and need treatment, management and observation of their condition and care by a professional.

Who can Participate in the Community Transitions Program?

Individuals who:

have a disability
are interested and willing to move back into the community
have Medi-Cal
are currently in a skilled nursing facility for 60+ days
have a home to return to (with family or their own) or who qualify for the NED Voucher*

Image of two DMC employees working using a laptop.

*To qualify for the NED Voucher, individuals must:

be between the ages of 18 -61
have a disability
be a legal citizen
have been residing in a skilled nursing facility for a period of at least 90 days
have been receiving Medi-Cal for at least one day

Please note all requirements must be met to be eligible for this program.

If you meet these qualifications and would like help moving back to community living, please call 714-621-3300 or complete DMC’s referral form by selecting Dayle McIntosh Center and Community Transition Services:

DMC Referral Form

Consumer Transitions phases - Left- DMCs Marisol Johnson with consumer Kara in her home Right -Conumer being helped to understand resources available

Who Can Make a Referral?

Self-referral – willing and eligible individuals who meet these requirements and need help moving back into the community.
Social workers, discharge planners, healthcare personnel, and family members may also refer individuals for transitioning services.

Pictured three older adults smiling standing together in front of artwork on a blue wall which reads “Aging, Age, Aging” to celebrate transitional milestones.

What is the Process for the Community Transitions Program?

Intake Process: A Community Transitions Coordinator will work with participant and their care team to complete a medical, functional, and cognitive assessment to determine if a safe and sustainable transition is possible.
Transition Care Plan: After it has been established that a safe and sustainable transition is possible, the Community Transitions Coordinator and the participant can work on a plan for a safe and successful transition by coordinating services which could include:

Transitions Consumer Marth with Mari in home with Xmas Tree

Finding adequate housing: Adequate housing can mean your own home/apartment or a family member’s home. If no current housing is available, persons who are 18 – 61 might be eligible for a voucher for rent subsidy through the Orange County Housing Authority (NED Voucher). Although income is not required to qualify for the NED voucher or to qualify for the Community Transitions Program, specific housing entities will require income proof to ensure that housing will be sustained.

If needed, the Community Transitions Coordinator will assist in finding financial assistance to cover deposits and moving expenses, purchase household items and coordinate home modification services.

Identifying and Providing Supportive Services: The Transitions Coordinator will help identify and provide supportive services needed such as skilled nursing care, in home supportive services, reestablish benefits, acquiring groceries, medication, obtaining assistive technology devices and durable medical equipment etc.
Providing post Transition Support: After transition is accomplished, Dayle McIntosh Center will continue to offer services and support for relocated consumers. If problems arise, the transition team helps to restore stability. Follow up contact is usually maintained with transitioned consumers for 90 days

Download our Community Transitions Flyer

Pictured, a successful transition story for a DMC Consumer. On the left we see a sunset sky in bright orange through clouds with the silhouette of a tree outside the consumer residence; next we see the consumer’s kitchen area, followed by their living room and bedroom area photos

A DMC consumer success story means creating a pathway through transition in the various stages of what that looks like from hospital, back into the community and returning to a place of independence. While transition may look different for every individual, the end result is about assisting through the difficult process to where the individual well-being is considered at every turn. The above photos are from our consumer’s experience. Read his story below.

PROGRAM SUCCESS STORIES

Consumer Returns to Independence and Sense of Self

61 year-old consumer who had been in a hospital for 2 years with complications from long- term COVID heard about the Dayle McIntosh center and the Community Transitions program from another patient in hospital who was a current DMC consumer. He wanted to move back into the community but didn’t know how to coordinate his transition. DMC was able to assist him through every step of the way and although there were many setbacks, he was finally able to move back into his own place. He is very happy in his own place and feels like himself again.

Consumer Meets Successful Transition

A 53-year-old female with multiple disabilities was discharged from a skilled facility after 17 years of residency. The Lead worked with the consumer to ensure all arrangements were in place for the discharge. Partnering with the DMC Reuse program, the Lead was able to provide the consumer with adult diapers and a commode. On the day of discharge, staff members gathered to say goodbye, with several emotional farewells and teary eyes. The consumer’s son, who serves as her caregiver, presented her with flowers outside the facility prior to entering the ADA accessible van. The consumer stated that it felt unreal.

Adapting to New Disability Creates New Independence

A 40-year-old female with multiple disabilities, including an arm amputation, with was discharged from a skilled facility after more than 2 years of residency. The Lead worked with the consumer and family to ensure all arrangements were in place for the discharge. DMC was able to provide a shower chair and a rollator using DMC Reuse program. On the day of discharge, the family expressed gratitude and were very pleased with the transition.

TESTIMONIAL:

‘I cannot thank DMC and the Community Transitions team enough. I am very happy. I live comfortably and I would have never gotten here if it wasn’t for DMC – Jose S.

Transitions Coordinator, Lizeth standing on ramp with clipboard outside DMC next to DMC blue logo sign with arrow pointing toward the door

DMC Frequently Asked Questions and answers masthead graphic in blue text with multicolored question marks inside speech bubbles on lower left corner, DMC Blue logo in center and multicolored exclamation marks lower right corner. Image has blue border.

Consumer Question: What is the Community Transition Program?

DMC Program Answer: DMC’s Community Transition Program assists individuals who are living in institutional settings such as skilled nursing facilities, intermediate care facilities for the developmentally disabled, state hospital for the mentally ill, rehabilitation hospitals, California Veterans’ home or acute care hospitals move back into a home in the community. The program supports individuals in finding the services, resources, and community-based supports needed for independent living.

Consumer Question: Am I eligible for the Community Transition Program?

DMC Program Answer: We assist people with disabilities, older adults, and Veterans who are currently in or at risk of entering institutional settings and want to live successfully in the community. Eligible individuals must meet program-specific requirements (such as Medi-Cal approval, income, and length of stay in a facility) and may return to an existing home or apply for housing assistance like the Non-Elderly Disabled (NED) voucher if eligible. We also provide short-term prevention or diversion support for non-CalOptima members who are at risk of institutionalization due to hospitalization, disaster displacement, or similar circumstances.

Consumer Question: Is there an income requirement?

DMC Program Answer: Participants must have a reliable source of income, even if it is not a large amount. Those eligible for the NED voucher will need to receive at least SSI or family support, while individuals not using a NED voucher must have sufficient income to cover ongoing monthly rent, as DMC can only assist with one-time move-in costs.

Consumer Question: I have a place to return to, but it’s no longer accessible for my needs. Can you still help me?

DMC Program Answer: Yes, we are able to assist in modifying your home through coordination with the Home Access Program at DMC. Home modifications are designed to help people navigate areas of their home with safety and ease to avoid worry and falls at home.

Consumer Question: How do I know if I am able to move back to the community?

DMC Program Answer: DMC works closely with your doctor, social worker, and other support persons while completing an individualized assessment to ensure it is safe, appropriate, and supportive for you to return to the community with the services you need in place.