From Hospital to Home

The Community Transition Care program provides support to older adults and adults with disabilities to successfully transition from a hospital setting back into the community and divert nursing home placement and re-hospitalization.

(The CTC program acts as a bridge between hospital and community services and resources).

Benefits of the program:

• Person-centered assistance.
• Options counseling and action planning.
• Streamlined access to Community services.
• Streamlined eligibility, access, and referrals to programs and services.
• Community resource navigation to address the Social Determinants of Health.
• Follow up for 120 days post-discharge for enrolled individuals.

Eligibility:

Individuals meeting any one of the following requirements are eligible for CTC services:

• 60+
• Medicare (MC)
• Medicaid (MA)
• Dual Eligible (MC and MA) Dorchester/Wicomico/Somerset/Worcester Counties