Over the next eight years, the Commonwealth of Massachusetts has committed to ensuring that 2,400 residents of long-term care facilities, like 71-year-old Jeanine at Timothy Daniels House, will get the help they need to transition back into the community. In June, with the help of the Community Transition Liaison Program at Springwell, Jeanine happily moved back in to her own home.

The Community Transition Liaison Program (CTLP), launched by the Massachusetts Executive Office of Elder Affairs in 2023, offers accessible, professional support including individually tailored discharge plans, connections to state program and local supports, and dedicated advocacy for nursing facility residents who want to return to the community. CTLP services are free for all nursing facility residents aged 22 and over, regardless of insurance status.

Transitioning to the community can mean returning to a family home, moving into accessible housing, or finding a residential facility that better meets a resident’s care needs. Each situation is unique, and the program tailors its response accordingly.

For Jeanine, the personalized attention of the CTLP program made all the difference. Jeanine’s case required a complicated coordination of a number of services. In April, understanding the challenges Jeanine would face in achieving her goal to move home, Heather Berry, Director of Social Services at Timothy Daniels House (pictured above right), connected Jeanine to Donna Murray, Springwell’s CTLP Supervisor.

Donna looped in Springwell’s Community Transitions nursing team to do the clinical assessments that determine the services that would be possible and then got to work coordinating all the moving pieces. The CTLP program prioritizes developing seamless partnerships between providers to improve outcomes for residents. In this case, Donna lined up Jeanine’s MassHealth re-enrollment and her qualification into the Personal Care Attendant Program. She also brought in the Money Follows the Person Program to fund the equipment Jeanine would need at home. Finally, she facilitated the timeline for services to begin with Jeanine’s local Aging Service Access Point, HESSCO, since Jeanine’s home was outside Springwell’s service area.

Jeanine, her family, and the staff of the Timothy Daniels House were delighted with the process and the outcome. According to Heather Berry, without the CTLP Program, Jeanine would not have been able to move back home.