How to Leave a Nursing Home and Return Home in New York: The NHTD Waiver Transition Track

# How to Leave a Nursing Home and Return Home in New York: The NHTD Waiver Transition Track

Many nursing home residents in New York don’t know they have the legal right to return to community living — and that Medicaid will pay for the support services that make it possible.

The NHTD Waiver Transition track exists specifically for this situation. If someone you care about is currently in a nursing facility in Monroe County or elsewhere in New York and wants to come home, this guide explains exactly how the process works.

The Core Principle: You Have the Right to Leave

Under federal and New York State law, individuals in nursing facilities have the right to discharge to the community. Nursing facilities are required to provide discharge planning. But facilities do not always proactively offer this information — families often have to ask.

The NHTD Waiver Transition track provides the framework for making that discharge safe and sustainable.

What Is the NHTD Waiver Transition Track?

The NHTD Waiver (Nursing Home Transition and Diversion) has two tracks:

• Diversion: For individuals currently living at home who are at risk of nursing home placement
• Transition: For individuals currently residing in a nursing facility who want to move back into the community

Both tracks provide the same services. The Transition track adds specific supports designed for the process of leaving the facility: community integration counseling, moving assistance, and the hands-on coordination needed to set up a safe home environment before discharge.

All NHTD Waiver services are funded by Medicaid for eligible individuals — no out-of-pocket cost.

Who Qualifies for NHTD Waiver Transition in Monroe County?

To qualify for the Transition track, a Monroe County resident must:

1. Currently reside in a nursing facility (or an intermediate care facility, hospital with extended stay, or similar institutional setting)
2. Have active New York State Medicaid
3. Meet nursing-facility level of care criteria — by definition, anyone already in a nursing facility typically meets this criterion
4. Want to return to community living — participation is entirely voluntary
5. Be able to live safely in the community with NHTD services — a Service Coordinator works with the individual to design a care plan that makes this feasible
Age: Must be 18 or older. For individuals 65+ with non-traumatic conditions, the NHTD Waiver applies. For adults 18–64 with a traumatic brain injury, the TBI Waiver may be more appropriate.

What Services Support the Transition?

The NHTD Transition track covers everything needed to make discharge possible and sustainable:

Community Integration Counseling
Helps the individual adjust to community living after a period of institutional care — rebuilding confidence, social connections, and daily independence.
Residential Habilitation
Skills training at home: cooking, managing a schedule, household maintenance, financial literacy. Particularly important for individuals who have been institutionalized for an extended period.
Home and Community Support Services (HCSS)
Daily hands-on personal care — bathing, dressing, grooming, meal preparation, mobility — provided by trained care workers.
Service Coordination
A dedicated coordinator who manages all aspects of the transition: discharge planning, housing arrangements, provider coordination, and ongoing care plan oversight after the individual is home.
Environmental Modifications
Physical changes to the home environment to ensure safety: grab bars, ramps, accessible bathroom fixtures, stair lifts.
Assistive Technology
Devices that support independence: communication devices, medication management systems, personal emergency response systems.
Moving Assistance
Practical help with the logistics and costs of transitioning from the facility to a community residence — particularly valuable for individuals who do not have family nearby to assist.
Respite Care
For family caregivers who will be providing informal support at home.

How Long Does the Process Take?

The NHTD Transition enrollment process typically takes 45–90 days from initial contact to services starting. This is why starting early is critical.

The process involves:
1. Initial eligibility screening (1–2 weeks)
2. Physician documentation and UAS-NY assessment (2–4 weeks, depending on scheduling)
3. Individualized Service Plan (ISP) development and NYSDOH approval (2–4 weeks)
4. Housing and environment preparation (varies)
5. Discharge and service start

Starting the NHTD enrollment process while your family member is still in the facility — not after discharge — is strongly recommended. Discharging before services are in place creates a safety gap.

Step-by-Step: How Monroe County Families Start

Step 1: Notify the nursing facility
Tell the facility’s social worker that you are pursuing an NHTD Waiver transition. Facilities are required to support discharge planning. Ask for a discharge planning meeting.
Step 2: Contact a licensed NHTD Waiver provider
Call Priority Cares at (585) 201-7179. Our care coordinators handle NHTD Transition enrollment for Monroe County residents. The initial consultation is free.
Step 3: Eligibility review
We review Medicaid status, diagnosis, and basic eligibility requirements. If the individual qualifies, we initiate the formal enrollment process.
Step 4: UAS-NY assessment and ISP development
A nurse or social worker conducts the standardized care needs assessment. A Service Coordinator develops the Individualized Service Plan specifying what services will be in place when the individual returns home.
Step 5: NYSDOH approval and discharge planning
Once the ISP is approved, discharge is coordinated between the facility, the family, and Priority Cares. Environmental modifications and home preparations are completed before the discharge date.
Step 6: Individual returns home
Services begin on the discharge date. The Service Coordinator remains in contact and monitors care quality ongoing.

A Note on Housing

The NHTD Waiver does not pay for housing. The individual must have a community residence to return to: their own home, a family member’s home, or a supported community setting. If housing is a barrier, discuss this with the Service Coordinator early — there are community resources that may assist.

Monroe County Families: Call Before the Crisis

The time to start NHTD Transition planning is not the day before discharge. Contact Priority Cares as early as possible during the nursing facility stay — ideally within the first few weeks if a long-term transition to home care is the goal.

Call (585) 201-7179 for a free eligibility review. Priority Cares provides NHTD Transition services across all Monroe County communities: Rochester, Greece, Irondequoit, Brighton, Henrietta, Webster, Penfield, Pittsford, Chili, Brockport, Victor, and surrounding areas.