Homeward Bound is designed to help elderly and disabled adults with complex, long-term care needs move from institutional to community settings.
It is also designed to help examine how best to help people transition and use this information improve Maine’s long-term care system beyond the grant period.
Homeward Bound is Maine’s Money Follows the Person program, a demonstration project funded by the Centers for Medicaid & Medicare Services (CMS).
To qualify for Homeward Bound, individuals must be 18 or older at the time of transition and:
- Have resided in a Nursing Facility and/ or Hospital for at least 90 days*, not including any short term rehabilitative stay and,
- Received Medicaid benefits for an inpatient hospital or nursing facility for at least one day and,
- Need institutional or nursing facility level of care, but for the provision of home and community based services.
* We are able to begin transition assistance prior to the 90 day mark.
Participation in Homeward Bound is voluntary and individuals are given their choice of available community housing options. In order to qualify for Homeward Bound Services, the participant must move to a “Qualified Residence,” defined by CMS as:
- A home that is owned or leased by the individual or a family member, or
- An apartment with an individual lease, or
- A residence in a community based residential setting in which no more than four unrelated people reside.
People who enroll in Homeward Bound are eligible to receive an individualized package of services and supports:
- All participants receive Transition Assistance facilitated by a Transition Coordinator who works with the individual and his or her team to better understand their needs, develop a transition plan and provide intensive help with transitioning back into the community
- Additional services are arranged according to individual needs and may include Home and Community Based Waiver Services (if eligible), Medicaid State Plan Services and Homeward Bound Demonstration Services such as Specialized Clinical Assessments, Independent Living Assistance, Household Start-Up, Enhanced Care Coordination, Technology Services, Planning Consultation and Peer Supports.
The Preliminary Assessment process is the first stage of the enrollment process. This stage includes three assessments: Self, Family/Friend, and Readiness.
During the transition planning process, the resident and team use the information collected from the assessment phase, determine eligibility for Homeward Bound, set goals and develop a solid plan to transition into the community. This will include a review of past and current services accessed by the individual.
The transition process is the final phase of enrollment into Homeward Bound. This stage involves carefully planning for moving day, and making sure all of the pieces are in place for a successful transition home. The Transition team assists the individual with enrolling in programs (if needed or desired), arranging and scheduling services and supports and setting up their new household.
Once home, a community coordinator helps to monitor the plan to ensure that the services in place are addressing the needs and works with the team to adjust the plan if needed.
Through the Homeward Bound program we will provide services to make sure the transition has been a success. The community coordinator will also help to make sure that, when the Homeward Bound program ends after 365 days in the community, necessary services are in place.
For more information
Maine Department of Health and Human Services
Office of Elder Services
Program Director: Frances Ryan