Nursing Home Transition Program

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Young adult in power chair with attendent with nursing home in background . people with disabilitiesWelcome Home is a Dayle McIntosh Center (DMC) program to assist individuals, who are in long-term residential care facilities such as nursing homes and rehabilitation hospitals to move back into the community. 

Helping consumers regain their independence from institutions is an important part of the DMC mission. 

Who Can Participate in the Welcome Home Program

People with disabilities, who reside in long-term institutions and who have the desire to live independently in the community are eligible to be participants in the transition program.

For more information about nursing home transition call 714.621.3300 or complete the online form.

Referral Process

Often people with disabilities, who live in long-term care facilities, contact the Welcome Home program on their own to inquire about transition services. Social workers, discharge planners, healthcare personnel, and family members may also refer individuals for relocation assistance.

How Transition Occurs

When a person indicates that he or she wants to move back into the community, an intake process is initiated. DMC contracts with a registered nurse, who completes a medical, functional, and cognitive assessment to determine if a safe and sustainable transition is possible. If identified obstacles can be addressed, a transition care plan is then developed and the coordination of services begins. The range of assistance available includes the following.

If the consumer does not have a home to return to and does not plan to live with family members, the location of adequate housing becomes a priority. Consumers, who are under the age of 60, may be able to obtain a voucher for rent subsidy through the Orange County Housing Authority. The Transition Coordinator helps to identify possible housing options. Often financial aid is needed to help cover deposits and the first month’s rent and program staff arranges such assistance.

In some cases, modifications must take place to make a unit accessible for people, who use mobility devices. DMC staff assists to identify funding for such modifications and locates a contractor to do the work.

People, who are leaving institutions after a lengthy stay, may not have furniture or other essential items for setting up a home. The Transition Coordinator may help with obtaining donations or purchasing household supplies.

Usually individuals relocating from nursing facilities need personal assistant services and may even require home healthcare. Assisting the consumer to find appropriate caregiver and medical support is another function of the transition program.

Additional services that may be provided include helping consumers to apply for or reestablish benefits, acquiring groceries, medication, and clothing, and obtaining assistive technology and devices. After transition is accomplished, Dayle McIntosh Center continues 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 2 years.

Following the closure of a case, the consumer is given an opportunity to complete a satisfaction survey to express his or her opinion regarding the effectiveness of the services provided through the transition program.

Program Success Story

A man was transferred to a skilled nursing facility upon release from the hospital. After more than a year in residential care, the man was longing to return home. He was referred to the Dayle McIntosh Center. Fortunately, the man was able to return to the house where he lived prior to going into skilled nursing care. The steps necessary to gain approval for his transition were coordinated by DMC. When he arrived back home, the consumer’s roommate and dog were waiting at the door for him. The consumer has settled back into his routine and has expressed extreme gratitude to be home again.

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