Nursing Home to Home Transition Program

Kissito at Home™: Bringing Our Seniors Back Into the Community

Kissito at Home™Kissito at Home is a nursing home to home transition program that allows a person living in a nursing home to transition back into their community with community based services.


To be eligible for Kissito at Home nursing home transition to home services a person must meet the following criteria:

  • Be a current resident of the Commonwealth of Virginia
  • Be living in a long term care institutional setting for at least 90 consecutive days (hospitalization days are included)
  • Be receiving Medicaid benefits for at least one day prior to enrollment

How does it work?

The Local Area on Aging is contacted by a social worker at the nursing home where the potential enrollee resides. The LOA will then make a referral to Kissito at Home and our Transition Coordinator will schedule a visit to determine if the potential enrollee is eligible for the program.

If it is determined that the potential enrollee is eligible, our Transition Coordinator will submit an application to the Virginia Department of Medical Assistance Services highlighting information about the new primary residence, services and items required to keep the enrollee safe in the community.

If approved for enrollment, the enrollee will begin a transitional care coordination plan that will begin 2 months prior to their transition and continue 12 months after their transition back into the  community is complete.

What services are available?

As part of your transitional care plan you will enroll in a Medicaid Community Based Waiver Program or PACE that will offer you access to many services you may need to remain safe and healthy in the community. In addition to the services offered through your Medicaid Community Based Waiver Program Kissito at Home provides access to the following:

  • Personal Emergency Response System (PERS)
  • Assistance with upfront household expenses
  • Assistive technology
  • Housing and transportation services

Who should I contact if interested?

  • Kissito at Home Transition Coordinator (540-904-2817)
  • Social worker where you reside
  • Local Office on Aging
  • Long Term Care Ombudsman