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Carlos looked at the blustery fall clouds out his window and dreamed of returning to his community and the place that felt like home.  However, Carlos faced significant long-term health challenges, which resulted in his placement in two different nursing facilities over a 6 month period.  Not only that, he no longer had a safe home to return to and began to lose hope. The Social Worker at the second facility recognized that Carlos could live more independently with support, so she began with a referral to the Area Agency on Aging of Western Michigan (AAAWM). The Community Transition Navigation Program was a perfect fit for Carlos.

The AAAWM Transition Team, Carlos, and the Nursing Facility Social Worker began to devise a plan for returning to the community. Amazingly, Carlos’ son spotted an apartment opening in the exact area where Carlos was hoping to move! With the help of the Transition Navigator and Housing Specialist, the apartment was secured and furnished, stocked with meals, the first month’s rent covered, and long-term supportive care plans established so Carlos could have the care he needed to stay living independently. 

Carlos believes that both divine intervention and the help of the Transition Navigation team allowed him to be set up for success!  He loves his accessible apartment, being near family and friends, and the ongoing support and care he receives through the MI Choice Medicaid Waiver Program.  He was all smiles as he shared stories of his time serving in the military and anecdotes about his family, and he was grinning just as big as we toured his new, beautifully appointed home. Looking out the window at the winter clouds in his favorite community, he was deeply thankful for a new start, a new Year, and a new home.

About Community Transition Services:

Community Transition Services assist those wanting to return to the community by:

• securing housing and/or arranging equipment to make the current home more accessible.
• setting up groceries and other household goods.
• coordinate referrals for in-home services through programs such as MI Choice Waiver, Care Management, and more.

Qualifications for Community Transition Services:

• reside in a facility.
• currently on, or eligible for, Medicaid.
• desire to return home or secure other housing (i.e., Apartment or assisted living).
• has a barrier to discharging safely from a facility in one of our 12 CTS counties (Allegan, Ionia, Kent, Lake, Mason, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, Osceola, Ottawa).

As a Local Contract Agency, AAAWM can also meet with those residing in a facility who indicate an interest in learning about community resources. The Area Agency on Aging of Western Michigan helps older adults and individuals with disabilities remain independent and provides support and education to caregivers You can reach out to learn more at (616) 456-5664 or visit www.aaawm.org.