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Nursing Home Transition and Diversion Service Coordination

Nursing Home Transition and Diversion Service Coordinators have been supporting Nursing Home-eligible individuals as one Service Coordination agency under the Department of Health’s Nursing Home Transition and Diversion program since 2008, and work in partnership with the individual to ensure that they receive the most appropriate supports based on their need and in the most integrated environment.

Nursing Home Transition and Diversion Service Coordination

According to Center for Disease Control’s National Center for Health Statistics, there were 1.3 million individuals living in nursing facilities in 2015. This number does not account for the number of individuals living in the community that may be eligible for nursing home care. Pathways, Inc. Nursing Home Transition and Diversion (NHTD) Service Coordinators have been supporting Nursing Home-eligible individuals as one Service Coordination agency under the Department of Health’s Nursing Home Transition and Diversion program since 2008. The NHTD Service Coordinators work in partnership with the individual to ensure that they receive the most appropriate supports based on their need and in the most integrated environment.

Services Provided

  • Focuses on keeping you in your home in the community
  • Assists in moving you from the nursing home environment to your home in the community
  • Meets with you in your home
  • Provides education on available services
  • Promotes choice
  • Secures needed assessments to maintain eligibility for services
  • Assists in obtaining and maintaining benefits and entitlements (Medicaid, Medicare, Food Stamps)
  • Links to doctors, specialists, day services, transportation, and in-home personal care supports

Population and Geographic Area Served

The Nursing Home Transition and Diversion (NHTD) Service Coordination program supports individuals in Broome, Chemung, Schuyler, Steuben, Tioga, and Tompkins counties under the guidance of the Department of Health’s NHTD Waiver. Individuals must be at least 18 years old, Medicaid-eligible, and have a documented physical or medical diagnosis.

NHTD Service Coordinators

The NHTD Service Coordinators are knowledgeable of the service delivery system and resources available for various physical/medical diagnosis, as well as elder care.

Contact

Pathways Inc. NHTD Service Coordination can help you or a loved one secure the supports and services necessary to foster continued life in the community. For more information, contact:

Manager, Care Coordination

Pathways, Inc.
33 Denison Parkway West, Corning, New York 14830
T: (607) 937-4520  F: (607) 937-3206

Care Coordination Services

These services provide care coordination to youth and adults with chronic medical conditions to get the care they need to improve their health and supports. Additionally, service coordination for individuals that are Nursing Home-eligible or have traumatic brain injuries.

Adult Care Management

Through Adult Care Management, a Care Manager partners with adults to get the care they want to improve their health and supports.

Children's Care Management

Through Children’s Care Management, a Care Manager helps youth and caregivers get the care they need to improve the youth’s health.

High Fidelity Wraparound

High Fidelity Wraparound is a national, evidence-based process that focuses on the goals of the family to address complex emotional and behavioral needs of the youth. 

Nursing Home Transition and Diversion Service Coordination

Nursing Home Transition and Diversion Service Coordinators have been supporting Nursing Home eligible individuals under the Department of Health’s Nursing Home Transition and Diversion program since 2008, and work in partnership with the individual to ensure that they receive the most appropriate supports based on their need and in the most integrated environment.

Recovery Coordination

Through Recovery Coordination, a Recovery Coordinator assists adults in Steuben County with Fidelis Medicaid Managed Care to gain peers and partners in the community.

Traumatic Brain Injury Service Coordination

Traumatic Brain Injury (Traumatic Brain Injury) Service Coordinators have been supporting individuals with TBI through the Department of Health’s TBI Waiver program since 1995, and work in partnership with the individual to secure supports and services that will allow them to live as independently and productively as possible.