The Community Transitions Liaison Program (CTLP) supports nursing facility residents who are interested in exploring a safe transition back to community living. CTLP staff work closely with residents, families, and caregivers to identify and address barriers to discharge, such as securing housing or arranging in-home services. The team also connects residents to appropriate state programs and local community resources.
Community Transition Liaisons conduct weekly visits at Tri-Valley’s 14 local nursing facilities. They collaborate with nursing facility social workers and discharge planners to obtain required documentation, assist with public benefit applications, and make referrals to programs such as Money Follows the Person (MFP) and Home and Community-Based Services (HCBS) waivers, which may provide supports including home modifications and additional in-home services.
CTLP services are available at no cost to all nursing facility residents age 22 and older, regardless of insurance type.