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Department of Aging and Community Living
 

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DACL's Community Transition Team

DACL’s Community Transition Team 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 18 and older with a disability
  • 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?

  • Community Transition Team 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 CTT 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
Contact TTY: 
711