How to Transition from a Nursing Home Back to the Community Through NHTD

Understanding the Pathway from Nursing Homes to Community Living

For many seniors and individuals with disabilities in New York, staying in their own homes is a priority that enhances quality of life and independence. The Nursing Home Transition and Diversion (NHTD) Waiver Program is a critical resource designed to support this goal. It provides tailored services that enable eligible individuals to move back into or remain in their community, rather than residing in nursing homes. This article explores how the NHTD program works, who it helps, the benefits it offers, and step-by-step guidance for accessing these services.

What is the NHTD Program?

Discover the NHTD Program: Supporting Independent Living in New York

What is the NHTD program?

The NHTD, or Nursing Home Transition and Diversion Waiver, is a specialized Medicaid initiative in New York State aimed at supporting elderly and disabled individuals to stay in their own homes or return there from nursing homes.

This program offers a broad spectrum of services, including case management, assistive technology, home modifications, community integration counseling, and daily living assistance. These services are tailored to meet each participant’s unique needs, fostering independence and promoting community involvement.

The goal of NHTD is to prevent unnecessary institutionalization by providing the necessary supports for individuals to live safely in the community. It helps participants transition smoothly from nursing homes or hospitals into a home setting or helps them maintain living arrangements in their current homes.

Eligible participants must be Medicaid recipients, require nursing home-level care, and prefer to live in the community. While the program serves those aged 65 and older, it also supports younger adults aged 18-64 who have disabilities. The program is managed through Regional Resource Development Centers across all counties in New York, ensuring wide accessibility.

Overall, NHTD aims to improve quality of life by empowering individuals with disabilities and seniors to live independently, with services designed to support their health, safety, and community participation.

Who does the NHTD help?

Is NHTD Right for You? Learn About Eligible Populations and Support

Target population for NHTD

The NHTD (Nursing Home Transition and Diversion) program is focused on helping Medicaid-eligible individuals who require a nursing home level of care but prefer to live in their own homes or community settings. This includes seniors aged 65 and older, as well as younger adults between 18 and 64 who have disabilities requiring similar levels of care.

The program targets people who can safely remain in or transition to community-based living with some assistance, rather than staying in or moving into institutional care like nursing homes.

Eligibility for seniors and adults with disabilities

Eligibility criteria encompass several important factors. Applicants must be enrolled in Medicaid and meet the functional criteria for nursing home-level care, which can include difficulties with daily activities, cognitive impairments, or medical needs such as injections or catheters.

Specifically, for seniors over 65, the focus is on those at risk of long-term institutionalization. For younger adults, particularly those aged 18-64, proving a physical disability and meeting the same care requirements is essential.

Financial limits also apply; the income threshold generally is about $1,800 per month, and assets should not exceed approximately $32,396 (as of 2025). Applicants must also have an identified living arrangement they wish to maintain or return to, ensuring their right to community-based living.

In addition, the program is not an entitlement, meaning available slots are limited, and some applicants may face waiting lists.

How the program supports community living

The NHTD program emphasizes a comprehensive, person-centered approach aimed at promoting independence and community integration. Once approved, participants receive a variety of tailored services such as case management and community integration counseling.

Key supports include home modifications to enhance safety and accessibility, assistive technologies to help with daily tasks, transportation services, and personal care assistance. These services are designed to reduce reliance on institutional care and help individuals live more autonomous and fulfilling lives.

In harnessing these services, the program not only works to prevent unnecessary nursing home placements but also actively supports individuals in maintaining their personal routines, social connections, and cultural ties within their communities. This holistic approach underscores the program’s core goal: empowering individuals to choose community living with the necessary support.

How can individuals transition from nursing homes to community with NHTD?

Steps in the transition process

Transitioning from a nursing home back into the community under the NHTD program involves several coordinated steps. Initially, the individual, often with assistance from family or caregivers, contacts their nursing facility staff or a designated NHTD provider, such as Acentra Health, to express the desire to return home. The process then begins with an assessment to determine eligibility, which includes reviewing medical necessity and functional needs. Following this, a comprehensive planning phase develops an individualized service plan that aligns with the person’s goals and needs.

The plan addresses essential aspects such as housing arrangements, community supports, medical care, and daily activities. Once the plan is in place and approved, service agencies coordinate to initiate necessary supports, including assistive technology, home modifications, and community engagement activities. With Medicaid approval and funding in place, the individual makes the physical move and begins receiving services in their community setting.

Role of discharge planners and specialists

Discharge planners, transition specialists, and Open Doors specialists play vital roles in this process. They provide information and support to residents and families, facilitate the application and assessment procedures, and help identify barriers to community placement. These professionals work to streamline transition plans, coordinate available services, and ensure that each participant’s preferences and needs are prioritized.

Their involvement extends beyond initial planning to ongoing support, helping individuals adjust to their new environment and access resources such as transportation, community activities, and healthcare services. Their expertise ensures a person-centered approach, promoting independence and community inclusion.

Application and assessment process

The application process begins with a referral—either from nursing homes, hospitals, or directly from the individual or family—submitted to the Regional Resource Development Center (RRDC). An intake meeting is scheduled to gather critical information, including proof of income, resources, and identity. A functional needs assessment, such as the UAS-NY (Uniform Assessment System for New York), evaluates the level of care needed.

Following this, an eligibility determination is made. If eligible, a service coordinator is assigned, and an individualized service plan is developed. The process involves review and approval stages, during which participants are informed of their rights, available services, and their involvement in decision-making. The entire process can take up to three months, highlighting the importance of early planning.

Importance of personalized planning

A hallmark of the NHTD program is its personalized, person-centered approach. Each participant's care plan is tailored to their unique needs, preferences, and life circumstances. Care plans include a range of services such as community integration counseling, assistive technology, environmental modifications, and personal care, all designed to promote independence.

Participants are considered the primary decision-makers, actively choosing their providers, services, and goals. This emphasis on personalized planning supports long-term success in community living, empowering individuals to maintain their independence and enhance their quality of life.

Services and supports for community reintegration

Services for Community Reintegration: Making Community Living a Reality

What services and supports are available through the NHTD program to assist with community reintegration?

The NHTD (Nursing Home Transition & Diversion) program provides a broad spectrum of services to help individuals transition from institutional settings like nursing homes back into the community or avoid entering these facilities altogether.

One of the main offerings is service coordination, where dedicated professionals develop personalized care plans tailored to each person’s specific needs and preferences. Community integration counseling is also available to support social engagement and help individuals build connections within their neighborhoods.

Support services extend to environmental modifications and assistive technology, facilitating accessible and safe living environments. These modifications might include installing grab bars, ramps, or other home adjustments, while technology solutions can include emergency response systems or adaptive devices.

The program also offers home and community support services, such as personal assistance with daily activities, respite care for caregivers, and structured day programs that promote daily engagement.

Transition services are a vital component, helping individuals navigate the move from long-term care facilities back to their homes. This includes logistical support like moving assistance and ongoing follow-up to ensure a smooth transition.

Additional supports include wellness counseling, which addresses medical and psychological needs, and peer mentoring to foster social skills and community connection.

Participants are encouraged to participate actively in selecting their services and providers, which promotes a person-centered approach that respects their choices and promotes independence.

Overall, these comprehensive services aim to empower individuals, improve their quality of life, and expand community inclusion, ensuring they live safely and with dignity in their preferred environment.

Eligibility criteria and application process for NHTD

How to Qualify for NHTD: Eligibility and Application Steps

What are the eligibility criteria for the NHTD waiver?

The NHTD (Nursing Home Transition and Diversion) waiver is designed for individuals who are Medicaid-eligible and need support to live in the community instead of a nursing home. To qualify, applicants must meet several specific requirements.

Firstly, they must be enrolled in Medicaid and require a nursing home level of care, which is typically determined through a standardized assessment such as the UAS-NY or H/C PRI. This assessment evaluates their ability to perform daily activities, cognitive function, medical needs, and behavioral health. If they demonstrate a need for continuous assistance with daily tasks, they likely meet this criterion.

Secondly, applicants should be aged 18-64 with a physical disability or 65 and older. For those under 65, verification through official medical documentation like SSI or SSDI is necessary.

Additional criteria include signing a Freedom of Choice form, which indicates their preference for community living over institutional care. They must also identify suitable living arrangements—either maintaining their current residence or finding accessible, affordable housing. Moreover, the individual or their guardian must be capable of managing or guiding their service plan.

Lastly, the planned services must be cost-effective and support the person's ability to live safely in the community. This involves regional and statewide review processes to ensure that the support plan meets these economic and safety standards.

What are the steps involved in applying and assessing eligibility?

The application process begins with an initial contact, often through discharge planners in nursing facilities or directly via regional centers like Acentra Health. An intake assessment is scheduled where the individual's needs are reviewed.

Following this, a comprehensive evaluation using tools like the UAS-NY or H/C PRI measures is conducted within the last 90 days to determine whether the individual requires nursing home level of care.

If eligibility is established, the next step involves selecting a service coordinator to develop an individual service plan tailored to the person's needs and preferences. This includes considering options for community integration, home modifications, and personal care.

Once the service plan is finalized, it undergoes a review process where the regional office assesses the plan’s appropriateness and cost neutrality. Upon approval, the individual is officially enrolled in the waiver program.

What documentation is needed to apply?

Applicants need to provide proof of income and resources, which include recent bank statements, income statements, and Social Security or disability benefits documentation. Identifying documents such as a birth certificate or driver’s license are also required.

Medical documentation confirming the need for nursing home level of care, such as recent assessment reports, is essential. If under 65, proof of disability through SSI, SSDI, or medical verification must be submitted.

Additionally, signed forms including the Freedom of Choice form and consent to participate are necessary. Proof of current living arrangements, such as lease agreements or property deeds, may also be requested.

Are there any considerations regarding waiting lists?

As the NHTD waiver is not an entitlement program, it operates with limited slots—around 3,234 per year—meaning there could be waitlists. Priority is often given to individuals in urgent need or those at high risk of institutionalization.

The application process can take up to three months or longer, depending on demand and the completeness of submitted documentation. Applicants are encouraged to submit thorough and accurate paperwork to facilitate a quicker review.

In summary, understanding the eligibility and being prepared with necessary documents streamline the application. Regional centers and discharge planners can provide assistance throughout this process, helping applicants navigate their options for community-based living.

Navigating Your Community Transition with NHTD

The NHTD waiver program provides a vital pathway for seniors and individuals with disabilities seeking to live independently in their communities. Understanding the eligibility criteria, available services, and step-by-step application process empowers individuals and their families to make informed decisions. Working closely with discharge planners, Service Coordinators, and regional centers ensures a smooth transition from nursing homes to home-based care. With a person-centered approach that promotes dignity, independence, and community inclusion, NHTD supports not only the physical move but also the ongoing success of living in the community. If you or a loved one are considering this option, reaching out to local resources and advocates can help navigate the process effectively, ensuring tailored care and a fulfilling life in the setting of your choice.