Homeward Bound

A Program to Help Nursing Home Residents Transition to the Community

Homeward Bound, Maine's Money Follows the Person program, is a demonstration project funded by the Centers for Medicare & Medicaid Services (CMS) created to assist residents of nursing homes to return to the community. The project also hopes to identify how best to help people transition back to the community and to improve Maine's long-term care system. The Ombudsman Program is the Referral and Advocacy Manager for Homeward Bound. The Ombudsman Program meets with anyone interested in Homeward Bound to explain the program, help them apply and if they are accepted, act as their advocate throughout the transition planning process.

The Ombudsman Program's role as advocates for long-term care consumers makes our participation in Homeward Bound a natural fit for the program and one that benefits Homeward Bound participants.

To be eligible, individuals:

  • Must be 18 or older,
  • Have resided in a nursing home or hospital for 60 days by time of discharge,
  • Received MaineCare for at least one day in this setting,
  • Qualify for nursing home level of care in the community, and
  • Plan to move to a qualified residence.

The Homeward Bound team will assist in creating an individualized transition plan. A Transition Coordinator, chosen by the participant, will work with the participant to identify the team. The team will work together to understand the participant's needs and create a plan for a transition back to the community.

Homeward Bound participants will receive support in accessing home and community based services as well as demonstration services including specialized clinical assessments, independent living assistance, household start-up, enhanced care coordination, technology services and more.

If you would like to learn about Homeward Bound from a participant’s perspective, please click here to watch Homeward Bound - Cindy's Story.

Homeward Bound will assist with the transition planning prior to the transition and monitoring for the first six months after the transition to the community. The Community Coordinator (usually the Transition Coordinator) will monitor the plan and work with the team to resolve any issues with the goal of creating a plan that will continue to meet the participant's needs in the community.

For more information about Homeward Bound or to make a referral please contact us or call us at (800) 499-0229 or (207) 621-1079. Homeward Bound is overseen by the Office of Aging & Disability Services, Maine Department of Health & Human Services, 41 Anthony Ave. SHS #11, Augusta, ME 04330, (207) 287-9200.