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Leaving the Hospital or a Nursing Home in Brooklyn: The Waiver Route Home
Discharge day can arrive faster than any family is ready for. When your loved one has a brain injury, or has been living in a nursing home and wants to come back to the community, New York’s waiver programs are one way to make home a safe option again. Here is how that route works for Brooklyn and Queens families.
Start the conversation before discharge
Ask the hospital or nursing home social worker two questions as early as you can: is a waiver an option for my family member, and can you document the care needs in the discharge papers? A clear record of the injury and the help needed with daily activities makes the eligibility step smoother.
How the waiver application moves
- Medicaid: your family member needs active Medicaid. If it is not in place, start that application now.
- The RRDC: the NYC Regional Resource Development Center reviews the application and confirms whether the person needs a nursing-home level of care.
- Choose a service coordinator: you pick a provider for service coordination, and the coordinator writes the service plan with you.
- Services begin: once the plan is approved, skills training, counseling and other supports start.
Each case moves at its own pace, so keep copies of every letter and write down who you spoke with and when.
Bridging the gap while you wait
The waiver is not instant. In the meantime, Medicaid or an MLTC plan may cover aide hours, and outpatient therapy can continue. Ask the discharge planner to set up follow-up appointments before your loved one leaves, and keep a simple daily log of what goes well and what is hard. That log is useful later when the service plan is written.
What waiver support looks like at home
After a brain injury, many people need help relearning routines: taking medications on time, getting to appointments, handling money, getting around the neighborhood. Independent Living Skills Training works on exactly those tasks. Community Integration Counseling helps the person and the family adjust, and a behavioral support plan can help if frustration or impulsive behavior is putting safety at risk.
A note on NHTD: New York State is not accepting most new NHTD referrals right now, and limited openings are released through the Regional Resource Development Center (RRDC). If your family member is already in the NHTD waiver, you can choose or switch providers. If they are new and have a brain injury, the TBI waiver is usually the place to start.
Where Priority Cares fits: in New York City (all five boroughs) Priority Cares Home Services is approved by the NYS Department of Health for the NHTD and TBI waivers: Service Coordination, Independent Living Skills Training (ILST), Community Integration Counseling (CIC) and Positive Behavioral Interventions and Supports (PBIS). On Long Island (Nassau and Suffolk) we are approved for NHTD Community Integration Counseling only. Other waiver-funded services, such as aide hours or home modifications, come from other approved providers that your service coordinator lines up.
This content is for informational purposes only and is not medical advice. Please talk with your doctor or care team about your own situation.
Frequently Asked Questions
Can someone start waiver services right after a hospital stay?
The waiver application takes time, so it rarely starts on discharge day. Ask the hospital social worker to note the brain injury and the person’s care needs in the discharge papers, and contact the RRDC early so the process is moving.
Does the waiver pay for aide hours at home?
Waiver plans can include supports such as home and community support services, delivered by approved providers. Personal care or home health aide hours usually come through Medicaid or an MLTC plan. A service coordinator helps you fit the pieces together.
Who do we call first?
Start with the hospital or nursing home social worker, then the NYC Regional Resource Development Center. A waiver provider can walk you through the steps.
If a loved one in Brooklyn or Queens is getting ready to come home, call (718) 400-6166 or visit prioritycareshs.com/contact to talk through the waiver route.
