How Community Transition Services Work
From Nursing Facility to Home
Not everyone who lives in a nursing facility wants to be there.
Some people ended up there after a fall, a surgery, or a health crisis. The plan was to recover and go home. But weeks turned into months, and going home started to feel impossible.
For others, it’s been years. But the desire to live independently again, to have their own space, their own schedule, their own front door - never went away.
Community Transition Services (CTS) is a program designed for exactly these people. It helps adults currently living in nursing facilities move safely back into the community, into their own home, an apartment, an assisted living facility, or another community setting.
If you’re a discharge planner or social worker looking for a reliable transition partner, this guide explains how CTS works and why it matters. If you’re a family member or someone living in a facility who wants to come home, this guide is for you too.
What Is Community Transition Services?
CTS is a coordinated support program that helps eligible adults move out of a nursing facility and into a community-based living situation. The program is operated by The Information Center in Wayne County, Michigan.
Here’s the simple version: if someone in a nursing home is ready to leave, medically, emotionally, or both, CTS helps make it happen. Safely, step by step.
The program helps with the real, practical challenges of moving back into the community:
• Finding housing — an apartment, assisted living, adult foster care, or a home of your choice.
• Covering transition costs — security deposits, first month’s rent, and essential move-in expenses.
• Furnishing your new home — furniture, appliances, kitchen supplies, bedding, and food to stock your pantry.
• Getting your documents in order — IDs, paperwork, and anything else you need to get settled.
• Connecting you to ongoing care — once you’re home, CTS connects you with in-home services so you’re not on your own.
• Transportation — visiting prospective housing or getting you physically moved from the facility to your new place.
CTS is available Monday through Friday, 9 AM to 5 PM. The program is funded through the Michigan Department of Health and Human Services (MDHHS).
How Is CTS Different from MI Choice?
This is one of the most common questions we get — from families and professionals alike. So let’s make it clear.
CTS and MI Choice are two separate programs. They often work together, but they do different things:
Community Transition Services (CTS) helps people move OUT of a nursing facility and INTO the community. It’s about the transition itself, housing, moving costs, furnishings, paperwork, and the initial setup.
MI Choice Medicaid Waiver provides ongoing in-home care and support once someone is already living in the community. It’s about the long-term care plan, meals, nursing, transportation, personal care, and coordination.
Think of it this way:
CTS gets you home. MI Choice helps you stay home.
In practice, they’re closely connected. About half of the people who transition through CTS go on to enroll in MI Choice for ongoing support. Others continue with community-based services through other programs. Either way, CTS makes sure no one walks out of a facility and into a gap.
How the CTS Process Works: Step by Step
Whether you’re a discharge planner coordinating a transition or a family member trying to understand what happens next, here’s what the CTS process looks like from start to finish:
1. A referral is made. This can come from a discharge planner, social worker, case manager, family member, or even the person living in the facility. Call The Information Center at 734-282-7171 or reach out by email.
2. TIC assesses the situation. Our team connects with the individual and their care team at the facility. We look at their goals, their health needs, and what kind of community living would be the best fit.
3. We find the right housing. TIC works to identify and secure appropriate housing, whether that’s an apartment, an assisted living facility, an adult foster care home, or another community setting. We help with the search, the applications, and the logistics.
4. We help cover transition expenses. CTS can help with security deposits, first month’s rent, and essential household items. Our team furnishes the new home with essential furniture, small appliances, bedding, kitchen supplies, and food. People shouldn’t move into an empty room.
5. The move happens. TIC coordinates the physical move — transportation from the facility to the new home, making sure everything is set up and ready when they arrive.
6. We connect them to ongoing support. Once settled, TIC connects the individual with in-home care services. For many, that means enrolling in MI Choice for long-term care coordination. For others, it means connecting with community resources that match their needs.
7. We follow up. This isn’t a handoff. TIC checks in to make sure the transition is going smoothly, the services are working, and the person feels safe and supported in their new home.
For Discharge Planners and Social Workers
If you work in a skilled nursing facility, rehab center, or hospital, you already know how hard safe transitions can be. Discharge deadlines are tight. Staffing is stretched. Readmission risk is real.
Here’s what CTS offers you as a referral partner:
• One point of contact. You work with a dedicated TIC team member who manages the transition from your facility to the community. Clear communication, predictable timelines.
• We handle the logistics. Housing search, move-in costs, furnishing, documents, transportation — TIC coordinates with you.
• Reduced readmission risk. A well-coordinated transition with ongoing care support means fewer people bounce back to the ER or the facility. CTS is designed to prevent that.
• Reliable follow-through. TIC doesn’t just drop off a patient. We connect them to services, check in regularly, and adjust if something isn’t working.
We know your time is limited. That’s why we’ve built a process that’s fast, transparent, and easy to work with. If you’re evaluating community transition partners, we’d welcome the chance to show you how TIC is different.
For People Living in a Facility (and Their Families)
If you’re reading this from inside a nursing home, or if your loved one is, we want you to know something – wanting to come home is not unrealistic. It’s not selfish. And for many people, it’s possible.
CTS exists because we believe people deserve the chance to live in the community when they’re able to. Not everyone can leave a nursing facility safely, but many people can, with the right support. That’s what CTS provides.
Here’s what you need to know:
• You don’t have to figure this out alone. TIC’s team helps with the housing search, the move, the paperwork, and the setup.
• You don’t have to have money saved up for a new apartment. CTS can help cover the security deposit, rent, furnishings, and food.
• You won’t be left on your own after you move. TIC connects you with in-home care and community services to make sure you’re safe and supported.
• Your voice matters. You help choose where you live, what services you receive, and who provides your care.
If you’re interested, talk to your discharge planner or social worker at the facility. They can connect you with The Information Center. Or you (or a family member) can call us directly at 734-282-7171.
Real Stories – Getting Back to Your Own Space
Here are stories from real people whose lives changed through Community Transition Services and The Information Center:
Mino was living in a nursing facility when TIC’s social worker, Marsha, helped him move into his own apartment five years ago. Today, TIC staff still check on him weekly. He has a caregiver named Sheila who helps him get things done, and Margreta at TIC coordinates his transportation to doctor’s appointments. Mino told us: “If anyone needed to transition out of a nursing facility, I would suggest calling The Information Center. They are good.”
One client worked with TIC’s Community Transitions Program after a long health battle that included cirrhosis of the liver. The program covered his security deposit and first month’s rent, furnished his apartment with appliances and furniture, and filled his pantry with food. He told us: “The wonderful people who work at The Information Center go beyond the call of duty to help others.”
Earl’s brother and sister-in-law, Ken and Kathy, had no idea how much TIC was doing behind the scenes — calling, sending information, and helping them make good decisions. TIC helped place Earl into a nice apartment Downriver and recently arranged transportation so he can attend church and play bingo in the community. Ken and Kathy said: “It does our heart good to know that Earl is doing so well. He has a whole new social life.”
Ebony was hospitalized and recuperating in a rehab facility when a staff member told her about The Information Center. TIC helped her and her 6-year-old daughter move into a larger, handicap-accessible apartment. The team furnished it with everything they needed and even provided Christmas gifts. Ebony said: “You are angels in disguise because of the love you all have for your clients.”
Dawn’s mother, Barbara, had one wish: to live in her own apartment. Even though Barbara’s health was declining, TIC staff members Elaine, Paris, and Alicia made it happen — moving her into her own place. Dawn told us: “I found a couple of angels. I couldn’t believe it. Mom was always happy. I am very grateful to The Information Center for caring for my mom.”
Every story is different. But the common thread is the same: someone in a facility wanted to come home, The Information Center helped them get there, and life got better.
Why Safe Transitions Reduce Readmissions
This section is especially for the discharge planners and social workers reading this.
When someone leaves a nursing facility without a solid plan, without housing, without services, without follow-up, the chances of ending up back in the ER or the facility go up dramatically. You’ve seen it happen.
CTS is designed to prevent that cycle. Here’s how:
• Housing is secured before discharge. No one leaves a facility without a confirmed place to go.
• The home is set up before they arrive. Furniture, food, supplies, and accessibility modifications are in place on day one.
• Ongoing care is arranged, not just suggested. TIC connects people to in-home services — and for many, that means full care coordination through MI Choice or other community programs.
• Follow-up is built into the process. TIC checks in regularly and adjusts the plan if something isn’t working. There’s no handoff into a void.
The result – people stay in the community. They don’t bounce back. And your facility’s readmission numbers reflect that.
Why Partner with The Information Center?
The Information Center has been serving Wayne County families for decades. We’re a nonprofit organization based in Taylor, Michigan, and our team includes nurses, social workers, community health workers, and trained specialists who know these programs inside and out.
Here’s what sets us apart as a transition partner:
• Dedicated team for CTS, your referral doesn’t get lost in a queue
• Full-service coordination, housing, furnishing, moving, documents, and ongoing care
• Direct connection to MI Choice, about half of CTS clients transition into our MI Choice Waiver program for long-term care
• Compassionate, reliable staff, the names in the client stories above (Marsha, Paris, Alicia, Elaine, Nikki, Margreta) are real people on our team
We’re not just a referral line. We’re a hands-on partner that stays with the individual from facility to community, and beyond.
How to Get Started
For Discharge Planners and Social Workers:
• Call 734-282-7171 and ask about Community Transition Services
• Email info@theinfocenter.org with the patient’s basic information
• We’ll connect with your team and begin the assessment process
For Individuals and Families:
• Talk to your discharge planner or social worker at the facility — ask them about CTS
• Or call The Information Center directly at 734-282-7171
• A family member can call on your behalf too
Either way, the process starts with a conversation. There’s no cost, no obligation.