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DACL's Community Transition Program

DACL’s Community Transition Program provides guidance, consultation, and coordination for home and community-based services, initial screenings, comprehensive assessments, completion of documentation, and coordination of services with nursing homes and rehabilitation facilities in DC, MD, and VA. In addition, the program serves as a resource for information on long-term care options and planning, as well as assisting with referrals for community resources.

Who is eligible for community transition services?

  • A District of Columbia resident age 60 and older or an adult with disabilities 18 years and older
  • Have been assessed for nursing home level of care
  • Have current DC Long-Term Care Medicaid
  • In Long- Term Care for 90 days or more OR
  • 90 days or less within 3-4 weeks of discharged from nursing facility
  • Needing assistance applying for and coordinating home and community-based services and supports

How are referrals received?

  • Referrals are received from the community, the client, family members, or legal representatives that call DACL’s Information and Referral/Assistance Unit: 202-724-5626
  • Referrals are received from nursing facility social workers via email. A completed Transition Referral Form with signed consents can be emailed to: [email protected]

What documents are needed to obtain benefits?

  • The Community Transition Program can assist the client in obtaining the needed documents
  • Government Issued ID or Passport
  • Birth Certificate
  • Social Security Card
  • Proof of Income

What benefits can CTP help clients obtain?

  • Money Follows the Person (MFP)
  • Medicaid and Elderly and Disabled Persons Waiver (EPD)
  • Social Security Disability (SSI and SSDI)
  • Medicare
  • Supplemental Nutrition Assistance Program (SNAP)
  • Behavioral Health Services
  • Metro Access
  • Durable Medical Equipment
  • Housing - client can be referred to CTP with or with housing

What types of housing in the community can clients have assistance to discharge to?

  • Private Residence
  • Home Sharing
  • Community Residential Facilities (CRF)
  • Assisted Living
  • Single Room Occupancy (SRO)

What if the client’s home is not accessible to safely live in the home?

The Safe at Home Program is available to provide modifications and adaptations made to minimize the risk of falls and improve accessibility – Examples include:

  • Chair Lift
  • Handrails
  • Bathtub cuts
  • Shower seat
  • Furniture risers
  • Grab bars


Frequently Asked Questions

What is Money Follows the Person?

Money Follows the Person (MFP) is a federal demonstration program that helps eligible individuals currently living in long-term care facilities – such as nursing homes, hospitals, and other qualified institutions – successfully transition back into the community. It is administered by the Department of Aging and Community Living’s Community Transition Program.

Who is eligible? Is this program for me?

· DC Resident

· 60 years of age and older; an adult with disabilities 18 years and older

· Eligible for the DC Elderly and Disabled Persons Medicaid Waiver (EPD)

· Currently living in a long-term care or hospital setting for at least three months

· Interested in living independently in the community

How does it work?

MFP provides the funds, services, and support you will need for a successful transition back into the community. Assistance is available to help you return to your current home or apartment. If that is not possible, other housing options including individual accessible apartments, assisted living, and group homes may be available. A Transition Care Specialist would be assigned to help you navigate the transition process, working with you and your care team on a one-to-one basis to develop a plan that’s right for you.

View more frequently asked questions here

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