Coming Home: One Story About Transitioning Out of Nursing Home Care

 In Your Community

In speaking of determination, perseverance, and the power of the human will, Maya Angelou once said, “You may encounter many defeats, but you must not be defeated. In fact, it may be necessary to encounter the defeats, so you can know who you are, what you can rise from, how you can still come out of it.”

As a Transition Coordinator for empowerline’s Community Transitions (formerly Money Follows the Person) program, I recently had the opportunity to work with a person who exhibited determination like this. Community Transitions is a federally funded Medicaid program, administered by over 40 states.

“Maggie” (name changed to protect her identity) had been living in a nursing home for several months following a hospitalization, but she knew she was ready to leave. She no longer needed the health and personal care services provided there, and she wanted to live life independently. So, in 2016, she applied to the Money Follows the Person program (today called Community Transitions), which transitions eligible people from long-term care facilities back into community settings.

That’s when she faced her first speedbump. Her leads for housing fell through again and again. In addition to that, she’d experienced problems in the past with housing credit, but she was determined to realize her dream of returning to the community. Maggie lacked much family support to help her find housing or to give her a place to live while she transitioned to independence, and the Social Services Department at her nursing home couldn’t help her either.

But she didn’t give up.

We advised her to place her name on several senior housing waitlists and to let us know when she had found housing. And we did hear from her. Maggie was maybe our only client ever to phone in regularly, “just to keep in touch and let you know that I’m still here,” she would say.

Two years passed this way. Finally, her moment came. With her credit issue resolved, Maggie was called by a HUD-subsidized senior independent living complex where she’d been on the waitlist.

There was one catch: there was a deadline to move her in, and it was swiftly approaching. The Community Transitions Team sprang into action.

When Transition Day arrived on September 27, 2018, Maggie moved into her new home. Empowerline’s Community Transitions program coordinated and provided:

  • Payment of Maggie’s security deposit and first month’s rent to make moving more affordable
  • Transportation from the nursing home to her new home
  • Purchase of furniture and household goods
  • Purchase of durable medical equipment that Medicaid would not cover
  • Peer supporters (people with a disability themselves who meet with others and help them understand how to get around in the community with their disability) to assist with her readjustment to the community
  • New dentures
  • CCSP (Community Care Services Program) Medicaid Waiver to provide case management and personal support services (i.e., aide in the home three days per week)
  • Visiting physician’s service on a monthly basis
  • Computer tablet recommended by peer supporters to connect her with the community and to improve socialization

The program works by coordinating the delivery of critical needs, such as durable medical equipment, assistive technology, home care services, and furniture, as well as other home and community-based services to ensure a safe and successful transition back to the community. It does all this by serving as a “redistribution” of Medicaid dollars from skilled nursing facilities to the community, indicating that Medicaid dollars may “follow the person” back to the communityLiving Room Couch with Side Table with better outcomes.

Dale Carnegie once said, “Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.” This was certainly true of Maggie. It was a pleasure working with someone who never lost sight of her dream to return to the community and to live her life to the fullest.


If you or a loved one are currently considering a move, empowerline is here to help. Our counselors can help you understand what long-term service options are available and how the cost of those services are covered. You can also learn more about your housing options on empowerline.


Leave a Comment

Related Posts

The A-B-Cs of Advocacy: Stand Up for Aging Issues that Affect Us All

When you feel passionately about an issue, whether it’s housing, transportation, the needs of caregivers, or something else that affects the lives of people who are aging or experiencing disabilities — a key thing to remember is that you can make a difference. How do we do it? Advocacy. We can all learn to clearly [...]

Voice Your Opinion on Important Issues for Older Persons

As the Area Agency on Aging (AAA) for the 10 county Atlanta region, the Atlanta Regional Commission (ARC) administers comprehensive aging and disability services that enable people to live in their homes and communities. The ARC AAA is adopting a new area plan for July 2020 through June 2024 to address the needs of the […]

A Spotlight: Cherokee County’s Services for Older People

I recently chatted with Tim Morris, the Director of Cherokee County Senior Services, about his leadership style and future plans for Cherokee County. Morris embodies the role of a fearless leader. From one project to the next, he continues to put his community first by assessing their needs to ensure high quality living. “The only [...]

Gain Independence and Self-Empowerment with Travel Training

The RSVP program trains adults ages 55+ to share knowledge on important subjects with their peers to help them to make informed decisions and choices with confidence. Topics range from disaster preparedness to managing your medications to healthy sexuality to how to use public transportation systems (known as travel training). Some volunteers are former educators [...]

Senior Hunger: What It Means, and What You Can Do

What comes to mind when you hear the term “senior hunger”? I imagine, like most of us, you think of people over the age of 70 not having enough food. If so, you’re at least partially right. Senior hunger is a broad term that has many different causes, but essentially, it means someone has a […]

Help three ways

Your needs come first. How can we help you? Call now, open a chat window, or leave a message for us to contact you later.

Looking for the latest guidance on the Covid-19 virus?

The CDC has created this video: “Covid019: What Older Adults Need to Know.”  You can also read CDC’s full list of pandemic-related recommendations.

If you are looking to connect with resources and services for older persons and individuals and disabilities in metro Atlanta, please contact us at or 404-463-3333.