At Circle of Care St. Louis, we believe that everyone deserves the opportunity to live independently in the comfort of their own home. Our Community Care Transitions Service is designed to support individuals who are ready to transition from a skilled nursing facility back into the community. We provide the guidance, resources, and personalized support needed to make this transition smooth and successful.

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What is the Community Care Transitions Service?

This service focuses on helping individuals safely and confidently move from a skilled nursing facility to their own home or community setting. We work with individuals and their families to ensure they have everything they need for a successful return to community life.

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Our Care Coordinators assist with:

• Creating a personalized transition plan tailored to your health needs, preferences, and goals.

• Coordinating necessary services and resources, including home care, medical equipment, and transportation.

• Navigating and securing subsidized housing for those who need assistance finding affordable housing options as they transition back to the community.

• Connecting you with community support services to help with daily living tasks, meal services, or financial assistance.

• Ongoing care management and follow-up to ensure a smooth transition and prevent rehospitalization.

 

How We Help

1. Comprehensive Transition Plan

Our Care Coordinators develop a detailed transition plan that addresses every aspect of your return to the community. From arranging home care services to ensuring your home is properly equipped, we provide the support needed to feel safe and secure.

 

2. Collaboration with Healthcare Providers

We work closely with your healthcare providers and skilled nursing facility staff to ensure continuity of care. Our goal is to make sure that your medical, social, and emotional needs are addressed during the transition process.

 

3. Access to Vital Resources and Subsidized Housing

We connect you with a range of community services that can help with daily living activities, transportation, and financial support. For those needing housing assistance, our Care Coordinators guide you through the process of navigating and securing subsidized housing to ensure that your living situation is affordable and stable.

 

4. Follow-Up Care and Support

Our commitment doesn’t end once you leave the facility. We provide ongoing follow-up support, including home visits and regular check-ins, to ensure your transition is successful and that you have access to the services you need over time.

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Ready to Make the Transition?

If you or a loved one is ready to transition from a skilled nursing facility back to the community, Circle of Care St. Louis is here to help. Our Community Care Transitions Service offers the comprehensive support you need to regain independence and enjoy a better quality of life.

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Complete the Central Intake Form Here