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# Transitions Out of Institutions

**Related Links**
                      - What's New
                      - Accessible, Affordable Housing
                      - Homelessness
                      - Supportive Services
                      - Traumatic Brain Injury
                      - Tribal Housing

Increased availability of housing choice vouchers coupled with recent changes to the Money Follows the Person (MFP) program and the enhanced federal funding available to states under the American Rescue Plan Act create an unprecedented opportunity for local, tribal, state, and national partnerships to help individuals who choose to return to the community to achieve their goal.

Transitions are a core service for centers for independent living (CILs).  Many area agencies on aging (AAAs) and aging and disability resource centers (ADRCs) offer services to assist with transitions back home from hospitals, nursing homes, or other institutions. 

 
                  - Nursing Home Transitions and Housing During COVID-19
                  -  Ensuring  community living has taken on even greater urgency due to COVID-19. People in nursing homes, congregate homeless shelters, and other institutions faced high risk of COVID-19 transmission, illness, and even death. The links below provide information and guidance to support people living in institutions to transition to homes in the community that have access to services and supports.                       - How CILs Can Initiate Emergency Relocations and Transitions During the COVID-19 Pandemic : recorded webinar about how emergency relocation programs during the pandemic differ from the core service of transitioning consumers out of institutions and congregate settings  
                    - Implementation of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid Home and Community-Based Services during the COVID-19 Emergency : letter to state Medicaid directors with guidance on how states can receive enhanced funding to increase access to home and community-based services (HCBS) for Medicaid beneficiaries 
                  - Transition Programs
                  -  The links below provide information about programs that help people transition to the community by providing access to both housing and services.                      - Health-Related Social Needs (HRSN) 1115 Framework : guidance clarifying an option states may consider employing in Medicaid managed care programs to reduce health disparities and address unmet HRSNs
                    - Community Mental Health Services Block Grant (MHBG) : gateway website about this funding program for community-based mental health services for adults with serious mental illnesses and children with serious emotional disturbances
                    - HUD Housing Choice Voucher Dashboard : information about voucher availability at the local level
                    - Mainstream Housing Vouchers : through this program, housing agencies can subsidize rent for people with disabilities who are younger than 62; priority is given to people who:                       - are transitioning out of institutional and/or other segregated settings, such as nursing homes, or are at serious risk of institutionalization
                      - are currently experiencing homelessness, previously experienced homelessness and are now a client in a permanent supportive housing or rapid rehousing project, or are at risk of losing their home 
                    - Mainstream Vouchers -- Serving Persons at Serious Risk of Entering or Transitioning Out of Institutional Settings:  topic guide that helps public housing authorities learn which entities may be able to provide support for transitions and how to find these potential partners
                    - Medicaid’s Role in Housing : report on how Medicaid programs can pay for certain housing-related services; includes a review of relevant federal guidance and authorities and examples of how certain states braid multiple funding sources to provide supports
                    - Money Follows the Person (MFP) : this program for Medicaid beneficiaries who choose to move from nursing homes to housing in the community with the services they need for independent living                       - MFP Expansion : notice with information about funding to support 20 or more state and territories to plan and implement a new MFP program
                      - Money Follows the Person Resources : technical assistance community for community-living professionals with information about Money Follows the Person and related resources  
                    - Projects for Assistance in Transition from Homelessness (PATH) : website with information about this federal funding source for services for people with serious mental illnesses who are, or who are risk for, experiencing homelessness
                    - Grants for the Benefit of Homeless Individuals GBHI) : website on this funding program to help communities expand and strengthen treatment and recovery support services for individuals experiencing homelessness who have substance use disorders or co-occurring mental and substance use disorders
                    - Treatment for Individuals Experiencing Homelessness  (TIEH): website on this funding program to help communities expand access to mental and substance use disorders treatment for people experiencing homelessness who have a serious mental illness, serious emotional disturbance, or co-occurring mental and substance use disorders 
                  - Transition Resources, Tools, and Partnerships
                  -  The links below can provide information on programs, networks, tools, and other resources that organizations can use to support transitions from institutions and community living.                      - Assistive Technology (AT) Programs : website with information about and resources on assistive technology that helps people with disabilities and older adults be independent, exercise choice and control over their lives, and engage in the community;                        - AT Toolkit : toolkit for aging and disability network organizations and others to improve awareness about AT, find resources to help select and acquire AT, and connect individuals with AT device and service resources
                      - State AT Directory : contacts for state AT programs 
                    - Care Transitions Community : website with a roadmap for No Wrong Door Systems and partners to begin or grow care transitions programs
                    - Choose, Get, Keep. . . Integrated Community Housing: A Supplement to ABCs of Nursing Home Transition: An Orientation Manual for New Transition Facilitators : guide for housing specialists and transition facilitators in centers for independent living (CILs) who work with people in nursing homes and other institutions to help them connect to integrated housing                       - Disability and Aging Networks : networks of local, state, tribal, and national organizations that help people attain voluntary services, find housing, and transition from institutions to homes 
                    - Community Transitions: Creative Collaborations Move People Home :  webinar featuring two states' programs that entail partnerships with nursing homes, hospitals, and community-based organizations to assist people with settling back into homes in the community and have reduced readmissions
                    - Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives : report on multi-agency state teams that linked health services and housing to more effectively help low-income and vulnerable populations become and remain successfully and stably housed, including transitions to the community 
                    - Funding Sources Successfully Used by States to Support Development of Integrated, Affordable, and Accessible Community Housing : quick-reference guide on housing resources that can be used to create integrated, affordable, and accessible housing and basic information on how to use these resources, including for transitions to community living
                    - How CILs Can Transform the Housing Landscape : on-demand training regarding solutions to expand accessible, affordable, integrated housing in communities 
                    - Restoring Lives: Building Integrated Communities and Strengthening Support : report on the 2012 Olmstead Implementation Best Strategies and Practices Policy Academy to reduce institutionalizations and support community integration
                    - Rural Housing Toolkit – Money Follows the Person (MFP) : toolkit with concrete resources that can help MFP providers, directors, outreach workers, and transition and housing coordinators identify and access the resources they need to help people leave institutional care and return to their rural communities  Visit the Accessible, Affordable, and Fair Housing page to learn about programs that are available to support people who are transitioning out of institutional or other segregated settings (or who are at serious risk of institutionalization).  Visit the Supportive Services that Make Community Living Possible page to learn about partnerships, solutions, and knowledge on home and community-based services that enable people with disabilities and older adults to live independently  
                  - Consumer Stories 
                  -                      - “Gladys & Linda Return to the Community” : 10-minute video documenting two individuals’ perspectives on returning home after living in a nursing home
                    - “Returning Home” – Money Follows the Person Rebalancing Demonstration participants’ video : 30-minute video documenting transitions of individuals from various institutional settings to homes with home and community-based services (HCBS) under the federal Money Follows the Person (MFP) Rebalancing Demonstration 

*Last modified on 02/28/2024*

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An official website of the Administration for Community Living, an operating division of the U.S. Department of Health and Human Services.