Community Transition Liaison Program (CTLP)

The Community Transition Liaison Program (CTLP) supports Nursing Facility residents (age 22+) regardless of insurance who is interested in receiving support & assistance to transition to the community.

CTLP provides in-reach, engagement and education to NF residents to understand their interest in returning to the community.

CTLP provides person–centered assistance, support and coordination for discharge planning, connects residents to state programs and local community support, housing options and assists with mitigating issues that may impact a successful transition to the community.

CTLP is offered through the Aging Services Access Points (ASAPs), which work closely with residents, families, nursing facility staff, housing providers, and community agencies. The goal of the program is to ensure that anyone who is clinically able—and wants to return to the community—has the support and resources necessary to do so.

Community Transition Liaisons offer individualized informed choice, engagement and education that include:

• Offering comprehensive information about options to receive long-term care services in the community.
• Addressing the individual’s strengths, needs, and concerns.
• Empowering the individual with the tools and support needed to actively participate in the decision-making process.
• Assessing transition readiness and identifying individual goals, preferences, and support needs.
• Providing education about community-based services, benefits, and housing resources.
• Coordinating with nursing facility staff to support discharge planning.
• Connecting individuals to services such as state-sponsored programs, in-home care, personal care, transportation, meal programs, and long-term services and supports.
• Helping gather required documents (e.g., IDs, financial records), applications, and referrals needed for community placement.
• Offering transition coordination to ensure that services and supports are in place on the day of discharge.
• Following up after discharge to confirm that the individual’s needs are being met once in the community.

These services are free and designed to reduce barriers that often make it hard for nursing facility residents to return home or to another community-based setting.

If you or someone you know is interested in exploring a transition back to the community, CTLP staff are available to help. Please contact your local Aging Services Access Point (ASAP) to learn more.