H.O.P.E. by AgeOptions is a Nursing Home Transition program. We assist individuals, 18 years and older, who have been living in a nursing home in Cook County for 60 days or more, and who are eligible for and/or on Medicaid, to transition back to the community. We help with skill building, services, supports, housing location and financing, and on-going case management to ensure a safe and successful transition from Nursing Home through Community.
10 Ways We Help You Move Back to the Community
Outreach
We meet with nursing home residents to educate them about the program, answer their questions, and assist them in joining the H.O.P.E. Program. We gather information that will assist in their transition to the community. Once a person has joined the H.O.P.E. Program they are moved to Assessment.
Assessment
We perform a full comprehensive assessment looking at past history, physical health, behavioral health, and functional needs. From there we create a plan with each person on the goals and steps that will be taken to move forward towards transition. Once the assessment and plan are completed, the participant moves to Pre-Transition.
Pre-transition
We assist participants in meeting their goals and steps to move forward with transition. This includes building life skills and other skills, and connecting with resources and supports to prepare for transition to the community. Once goals are achieved, the participant moves to Transition.
Transition
We arrange services that will be needed in the community, provide education, and ensure support is in place for a safe transition. We work closely with the participant, their family/friends, the nursing facility, and community supports, including the Managed Care Organization, to ensure a successful transition to the community. Once the participant transitions, they move to Community Integration.
Community Integration
We assist participants for 18 months once they transition to the Community. We provide additional skill building, link them to resources and services, discuss harm reduction and crisis planning and work with participants to meet their goals to live safely and successfully in the community after they graduate from H.O.P.E.
Data & Compliance
We support the various teams and participants to ensure a smooth transition from nursing facility through community. We assure H.O.P.E. remains compliant with all requirements.
Legal/Income
We help participants apply for Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). We gather the necessary documents and provide representation with the Social Security office until there is a decision about a participant’s income.
Housing
We work with participants to identify affordable housing in the neighborhoods that they wish to move to. We arrange tours, assist with housing applications and lease signing. We ensure that eligible participants receive rent subsidy, and their new units are made accessible. We help participants select furniture, supplies and food and ensure unit is set up prior to their move.
Assertive Community Treatment (ACT) / Community Support Team (CST)
Our multi-disciplinary team provides supportive services to work with participants on their mental health goals in the community. This can include medication management, counseling, skill building, regular check-ins, support groups and other therapeutic services and support.
Employment
We help participants find a path towards their employment goals using their existing education, skills, and experience. We identify careers that will lead to long-term success, assist with resume development, and help people prepare for interviews with one-on-one counseling and practice interviews.
