Nursing facilities were never meant to be permanent homes for everyone placed in them. A significant percentage of skilled nursing facility residents — including many in Orange County — would prefer to return home or move to a community setting, and many could do so successfully with the right support.
CalAIM has made this transition more achievable than ever before.
The Nursing Facility Transition/Diversion Benefit
Under CalAIM’s Community Supports framework, Medi-Cal managed care plans can fund Nursing Facility Transition and Diversion services — a specific benefit designed to help people move out of nursing facilities and return to community living.
This benefit can cover: assessment of what supports are needed for a safe home transition, help finding appropriate housing if needed, coordination of home care services, procurement of durable medical equipment, home safety modifications, and care management during the transition period.
For families who placed a parent in a skilled nursing facility — perhaps after a hospitalization when there seemed to be no other option — this benefit represents a real pathway back home that many never knew existed.
Is a Home Transition Realistic?
The right questions: What level of ongoing care does the person need? Can that care be provided in the home environment? Does appropriate housing exist? Is there family or community support available?
For many individuals, the answer is yes — with professional in-home care, the right home setup, and care coordination, a return home is both safe and preferable to continued facility placement.
The Role of the Care Team
A successful nursing-to-home transition requires coordination between the SNF discharge team, the Medi-Cal managed care plan, any IHSS services being arranged, and the in-home care provider. This is not a handoff — it’s an orchestrated transition that requires someone holding all the pieces together.
Care partners has experience in these transitions. We assess what care will be needed at home, coordinate with the managed care plan regarding CalAIM coverage, and provide the professional in-home care that makes the transition sustainable.
Call Care partners to discuss nursing facility transition planning in Orange County.