NC Community Living Program: North Carolina's Bridge for Nursing Home Transitions Back Home

Most families think of Medicaid home care programs as tools to keep a parent out of a nursing home. North Carolina's Money Follows the Person (MFP) program works in the opposite direction — it helps eligible Medicaid beneficiaries who are already in a qualifying facility transition back into the community when they want to leave and a safe home care plan can be established. Families may also encounter the phrase "NC Community Living Program" when searching for this kind of transition support.

What the Program Does

North Carolina's MFP program is a federally funded NC Medicaid transition initiative. The program provides:

• Transition coordination — a dedicated case manager who works with the nursing facility, the Medicaid beneficiary, and the family to plan every aspect of the move back home
• Housing transition assistance — help with eligible rent or utility deposits and connecting with housing resources when needed
• Home setup costs — one-time assistance for eligible essentials such as furniture, household items, home modifications, and food
• Ongoing community-based services — once the person transitions, they may connect to CAP/DA, TBI, NC Innovations, or PACE, depending on eligibility and program availability

Who Qualifies

The MFP program serves Medicaid beneficiaries who:

• Have resided in a hospital, nursing facility, or other qualifying facility for at least 60 consecutive days
• Want to return to a community setting — their own home, a family member's home, or an independent apartment
• Can safely receive the care they need in the community, as determined through a clinical assessment
• Have community Medicaid coverage and approval for home- and community-based services (HCBS)

The person does not need to be clinically "improved" simply because they are transitioning. The transition plan must show that the person can be supported safely in the community, and the ongoing service may be CAP/DA, TBI, NC Innovations, PACE, or another approved arrangement rather than one single program.

Why Families Do Not Know About It

MFP can be underused because families often do not know to ask about a transition after placement. Nursing homes and hospital discharge teams may focus on immediate care arrangements, while families who have gone through the emotional exhaustion of placing a parent in a nursing home may not think to ask whether the move can be reversed.

But the program exists precisely for situations like these:

• A parent was placed in a nursing home after a hospital stay because no home care plan was ready in time, but the family has since arranged the support needed
• A parent's condition has stabilized after a period of intensive medical intervention, and they no longer need 24-hour nursing supervision
• A parent explicitly wants to return home and the family is willing to coordinate community-based services

How to Start

Ask the nursing facility's social worker or call the NC Medicaid Contact Center at 888-245-0179 about the MFP transition process. The transition team will:

1. Assess the person's clinical needs and preferences for where they want to live
2. Coordinate with the county DSS to ensure Medicaid eligibility continues in the community setting
3. Coordinate the approved HCBS services and other supports identified in the transition plan
4. Arrange the housing, home modifications, and essential household setup
5. Connect the person with ongoing care — CAP/DA, TBI, NC Innovations, PACE, or another approved HCBS arrangement

The transition is not instant. Planning typically takes several weeks to a few months, depending on housing availability and the complexity of the care plan. But the program covers the transition costs that would otherwise fall on the family — and once the person is home, the ongoing care runs through the same Medicaid programs that serve people who never entered a facility.

The Bigger System

MFP is one piece of North Carolina's HCBS landscape, alongside PCS, CAP/DA, Special Assistance In-Home, PACE, and local services. The Aging in Place in North Carolina guide maps these programs in a single framework, including the clinical and financial eligibility criteria for each, so families can see where MFP fits and what comes after the transition home.

See more North Carolina guides →