Take Me Home West Virginia: The Nursing Home Transition Program

Most families assume that once a parent enters a nursing home, the move is permanent. In many cases it does not have to be. West Virginia's Take Me Home program is designed specifically to help nursing home residents transition back to community living — returning to their own home, a family member's home, or another community setting where they receive waiver-funded in-home care instead of institutional care.

For families of parents with dementia, this program matters in two situations: when a parent was placed in a nursing home during a crisis and the family has since built the capacity to manage care at home, or when a parent was placed because in-home waiver services were not available fast enough and those services are now accessible.

How the Program Works

Take Me Home is West Virginia's implementation of the federal Money Follows the Person (MFP) initiative, which incentivizes states to move Medicaid-eligible residents out of institutional settings and into community-based care. The program provides transitional support — both financial and logistical — to bridge the gap between the nursing home and the community setting.

Eligible participants receive:

Transition coordination. A transition coordinator works with the resident, the family, and the nursing facility to develop a concrete plan for returning to the community. This includes identifying housing, arranging in-home care services, coordinating medical equipment needs, and ensuring that the home environment is safe and accessible.

Start-up costs. The program covers one-time expenses associated with setting up a safe home environment — security deposits, utility reconnections, essential furniture, basic household supplies, and adaptive equipment. These are costs that families often cannot cover after months of private-pay or Medicaid-funded nursing home care has depleted savings.

Ongoing waiver services. Once the participant transitions, they are enrolled in the Aged and Disabled Waiver (ADW) to receive in-home care services. Under the ADW, participants keep 100% of their monthly income (compared to the $50 Personal Needs Allowance in a nursing home), making community living financially sustainable.

Eligibility Requirements

To qualify for Take Me Home, the participant must:

• Be a current resident of a Medicaid-certified nursing facility
• Have lived in the facility for a minimum continuous period (typically 90 days)
• Meet Medicaid eligibility requirements
• Be clinically appropriate for community-based care (the care team must determine that the person's needs can be safely met outside the institutional setting)
• Want to transition — the program is voluntary

For parents with dementia, the clinical appropriateness determination is the critical gate. A parent with early-to-mid-stage dementia who has a reliable caregiver at home and whose wandering and behavioral symptoms can be managed with in-home support may qualify. A parent with advanced dementia requiring 24-hour skilled nursing intervention typically will not.

The Financial Advantage

The economics of transitioning from a nursing home to home-based waiver care are dramatic:

In a nursing home: Your parent keeps $50 per month. Everything else — Social Security, pension, IRA distributions — goes to the facility as patient liability.

On the ADW at home: Your parent keeps 100% of their monthly income. Medicaid-funded services cover in-home personal care, and programs like Lighthouse and FAIR can supplement.

For a parent receiving $1,800 per month in Social Security, the difference between $50 and $1,800 available for living expenses is the difference between financial survival and financial crisis for the family.

Practical Considerations

The transition is not simply a discharge. It requires active planning:

Home readiness. The home must be evaluated for safety — grab bars, wheelchair accessibility if needed, door alarms for wandering prevention, medication storage, and caregiver sleeping arrangements for overnight supervision.

Care team assembly. Before the transition date, ADW services must be arranged. Under the Personal Options Model, family members can be hired as paid caregivers through a fiscal intermediary. Under the Traditional Agency Model, a licensed home care agency provides workers.

Medical continuity. Prescriptions, specialist appointments, and therapy schedules must transfer from the facility's internal coordination to the family's management. This is where many transitions stumble — the nursing home was handling medication management, and now that responsibility shifts to the caregiver.

Caregiver capacity. Honest assessment is essential. If the original nursing home placement happened because the primary caregiver was physically or emotionally exhausted, returning to that arrangement without additional support services will reproduce the same crisis.

Starting the Process

If your parent is currently in a West Virginia nursing home and you believe community transition is feasible, start by contacting the Bureau of Senior Services to ask about the Take Me Home program. The nursing facility's social worker can also initiate a referral.

The transition coordinator will assess the situation — the participant's clinical status, the proposed living arrangement, available support services, and caregiver readiness — before a transition plan is developed. The entire process typically takes several months from initial assessment to actual move-out.

The West Virginia Dementia & Memory Care Guide covers both directions of the care transition — from home to facility and from facility back to home — including the financial worksheets for comparing patient liability against ADW community living costs.

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