Empowering people to thrive as they age.

Facilities

Empowering individuals to move from nursing facilities to community based living.

About the Program

Home Options Path to Empowerment (H.O.P.E.) by AgeOptions is funded by the Department of Human Services under the Colbert and Williams Consent decrees to help eligible nursing facility residents move into the community and live as independently as possible.

Our coordinated, comprehensive process provides a seamless, person-centered experience that safeguards against delays and service gaps, and helps individuals thrive in their community-based setting. Just like the heart in the middle of our logo, residents are at the center of everything we do and wrapped in our support.

Our Process

You’ll be able to talk to us at your facility –H.O.P.E. by AgeOptions will be serving patients through telehealth during the national public health emergency. Telehealth — sometimes referred to as telemedicine — is the use of 2-way video conferencing that allows us to have safe and confidential conversations with you.

We work with recommended and self-referred individuals to establish a transition plan and coordinate necessary support services to successfully move them from your facility to an appropriate community setting.

We have identified the most experienced aging organizations, including Aging Care Connections, Heartland Human Care Services, North Shore Senior Center, and PLOWS Council on Aging, to be our partners in this process.

Here are the 6 steps involved in our process:

1) Outreach

A dedicated Home Team Coordinator reaches out to and engages with referred or interested individuals.

2) Assessment

Our Home Team evaluates individuals to determine if they qualify for the program, a meeting is arranged with your facility’s care team, and results are discussed.

Note: Individuals who are not recommended for transition after the assessment receive goals to work on and are eligible for re-evaluation within 6 months.

3) Transition Planning

When individuals qualify for transition, the Home Team develops a customized plan based on their needs and goals. We help them gather necessary documentation, find the right housing, set up the household, build essential skills, navigate the new neighborhood, and connect to community services.

4) Transition

The Home Team Coordinator ensures individuals are connected to necessary services and are ready for moving day such as coordinating furniture, food, and medication deliveries.

5) Monitoring

For the first three months at a minimum, the Home Team will conduct monthly home visits to assess the health, welfare, safety, and changing needs of the individuals. These visits will continue as long as necessary. The goal is to ensure the individuals choose to continue successfully residing in the community.

6) Independent COMMUNITY Living

As individuals demonstrate they can successfully live in the community with any necessary supports, the Home Team gradually minimizes its involvement and seamlessly transfers monitoring to Managed Care Organizations’ care coordinators.

Our Multidisciplinary Team Approach

  • Reaching out to and engaging with recommended or self-referred individuals
  • Evaluating their needs
  • Understanding and supporting their hopes and goals
  • Finding appropriate housing
  • Preparing them to move back into the community

Eligibility

For over 45 years, AgeOptions has been committed to partnering with nursing facilities and community-based organizations to provide innovative services and resources to empower older adults and people with disabilities to thrive in their communities.

To be eligible for our H.O.P.E. by AgeOptions services, an individual must:

  • Reside in a Cook County nursing facility
  • Be at least 18 years old
  • Qualify for Medicaid
  • Be recommended by our team for transition after an assessment

Your Facility’s Role and Benefits

We will handle all of the work and respect your staff’s busy workloads, but per the consent decrees your staff will need to help us obtain case records and contact information for residents’ significant others and guardians.

In recognition of your support, we will share our work together on this program through our newsletter, social channels, and print media with our network of medical professionals, community health workers, experts on aging, social workers, clients, caregivers, legislators, and others.

We also have an annual award program that recognizes facilities who help us successfully move individuals to the community. In addition, we frequently refer caregivers looking for out-of-home respite to facilities that their care recipient can try on a trial basis.

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