What are Nursing Facility and Hospital Transition Services?

Circle of Care, St. Louis, is dedicated to guiding you through transitioning from long-term care facilities or hospitals to your home or another community-based residence.

 

Where are Transition Services Offered?

Circle of Care, St. Louis, offers transition assistance to eligible individuals in St. Louis City, St. Louis County, and St. Charles County.

 

How do I enroll?

To begin exploring your options within the Nursing Facility and Hospital Transition (NFHT) program, we encourage you to complete our central intake form, which is the preferred method for enrolling in our services. This initial step involves a thorough assessment to determine if you qualify for the program.

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What can I expect?

Upon completing the intake process, our team will contact you for an initial discussion and may schedule a more detailed interview to provide an in-depth understanding of the NFHT Program. Active participation in crafting a transition plan that reflects your specific needs and choices is crucial. For those planning to return to their homes, we offer evaluations to recommend necessary modifications for a seamless transition. We also support locating affordable housing and identifying essential programs and services to uphold your independence.

 

How do we help?

Our approach includes coordinating your transition from a nursing facility or hospital to a community-based setting and managing any long-term care services you may require for ongoing independence.

 

In the transition process, you’ll have access to services such as:​

• Housing Leads 

• Navigating Medicaid and Medicare  

• In-Home Personal Care Services such as... light housekeeping, dressing, grooming, bathing, errands, etc. 

• Medication Setup and education 

 

Transitioning may require time to ensure a safe and successful return to the community.  You may pause or stop this process at any time and choose to remain in your current situation.

 

Who is eligible? To be eligible for the NFHT program, you must:

• Currently reside in a nursing home or be admitted to a hospital, wanting to return home.

• Be eligible for and receive Medicaid.

• Wish to return to your own home or move to another community-based living option.

 

How do I make a referral?

Referrals for the NFHT program can be made by filling out our central intake form. This can be done by the person seeking the transition or by anyone concerned about their well-being. To initiate the process or for more information, please access our central intake form.