From Nursing Home to Your Home


A Guide to the Transition Process

All Virginia residents who are Medicaid eligible have the right to receive long-term care in the least restrictive and most integrated setting, including home and community based service. Starting in 2007, Virginia has participated in the Money Follows the Person Project (MFP) which provides the resources to offer individuals a choice where they live and to receive services and support necessary to move from an institution and live in their own community.

Eligibility. To participate in the Money Follows the Person Project, the individual must:

  • Be a resident of Virginia
  • Have lived in an institution for a minimum of six months
  • Have been eligible for Medicaid for at least one month
  • Qualify for a Medicaid waiver program
  • Move to a qualified residence in the community (this can be a private residence or a group home of no more than four unrelated individuals).

Services offered under the MFP include:

  • A personal transition program developed by an approved Transition Coordinator
  • Assistance with payment for up-front household expenses
  • Up to $5000 for home modifications such as ramps, grab bars, and door-widening.

Who is involved? What is the transition process?

  • It starts in the Nursing Facility. The Nursing Facility staff will ask each resident (or a designated representative) directly if he/she wants to talk to someone about the possibility of returning to the community. A form called a Section Q is used for this purpose.
  • If the resident desires to talk to someone about returning to the community and has signed the Informed Consent Form the Nursing Facility contacts the Local Contact Agency (LCA) (Alison Kron in the Fairfax County Disability Services Planning and Development staff, 703-324-5414). The LCA in turn contacts the individual resident with information pertaining to available community services and resources, and a list of Transition Coordinator Providers (TCP), currently the Endependence Center of Northern Virginia (703-525-3268) and Brain Injury Services (703-451-8881).
  • If the resident desires to continue the process, the Nursing Facility contacts the LCA which will refer the resident’s information to the designated TCP which arranges for a face-to-face meeting with the resident to discuss available community services and to initiate a plan for transitioning to the community.

Questions and Answers:

  • Q. I am a resident in a Nursing Facility and I want to talk to someone about moving back to my community. To whom should I talk?  

A.    Your Nursing Facility Administrator or Discharge Planner.

  • Q. What services are available under the MFP Project?

A.    The services must be sufficient to enable a person to live independently in the community and may typically include help with daily activities, housekeeping, home modification and accessibility adaptations, home delivered meals, and a wide variety of other services for living independently.

  • Q. How long will the MFP Project continue?

A.    MFP was originally designed as a demonstration project to run from Fiscal Year 2007 to Fiscal Year 2011, and was extended by the Patient Protection and Affordable Care Act to Fiscal Year 2016.

  • Q. What happens when MFP ends?

A. Funding will continue under the various Medicaid waiver programs.

  • Q. Where can I learn more about the MFP Project and the services available for      moving back to my community?

A.    See the list of references and resources, most of which are available via the internet.


References and Resources:

The Money Follows the Person Project
Web: www.olmsteadva.com/mfp. This is the official Virginia website for the Money Follows the Person Project. You can obtain:

    • The Money Follows the Person Brochure which contains all of the essential information in abbreviated form.
    • The MFP Project Guidebook which contains detailed information on the project. The Table of Contents is very comprehensive and allows the reader to quickly identify specific areas of interest. Appendix 5 of the Guidebook is the Informed Consent Form which must be voluntarily signed in order to participate in the MFP Project.
    • The MDS 3.0 Section Q. From this link you can view the Section Q questionnaire found at Appendix 1 to the MDS 3.0 Section Q Pilot Test Interim Report, and the Statement of Understanding between the principal agencies and participants in the MFP Project.

Money Follows the Person Rebalancing Demonstration: A Q&A for Public Housing Authorities
Web: www.neweditions.net/housing/resources/82_MFP_Q&A_for_PHAs-2010.pdf . Although designed for public housing authorities this web site contains considerable explanatory information on the MFP Project in easy to understand question and answer format.

Rental Choice VA

Information about the DOJ Settlement Agreement with the Commonwealth of Virginia

The Fairfax County Local Contact Agency (LCA): Alison Kron in the Fairfax County Disability Services Planning and Development staff, 703-324-5414; email: alison.kron@fairfaxcounty.gov, FAX: 703-449-8689, TTY: 703-449-1186.   




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