The consumer will provide direction regarding the discharge to the community. The transition team will consist of the consumer, the transition coordinator and nursing home staff, including social work, physical therapy and nursing.
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The Nursing Home Transition Program serves nursing home residents age 18 or older living in Luzerne / Wyoming Counties. A Transition Coordinator is available to visit residents who have expressed a desire to return to the community. The Transition Coordinator gathers information about community resources and collaborates with a Transition Team chosen by the resident.
With the help of the Transition Team, the resident receives information about his/her specific care needs, safety issues, and services available in the community. The resident then decides whether it would be best to transition to the community or remain in the nursing home.
The Nursing Home Transition Coordinator is directed by the resident to help with arrangements for housing, in-home services, help from family or friends, and transportation services depending on what the resident’s specific needs in the community will be.