Vital Community Services provides Service Coordination (Act 150 & OBRA), Comprehensive Transitional Integration, and Community Integration Services for individuals receiving or seeking long-term services and supports through Pennsylvania’s Office of Long-Term Living (OLTL). 

 We work quickly to begin discharge planning and coordination, helping individuals transition safely from hospitals, rehabilitation centers, nursing facilities, and other care settings into stable community living. Our goal is to reduce delays, prevent avoidable readmissions and connect individuals to the supports and resources needed for long-term stability and independence. 

Our focus is simple: connect individuals to the right supports so they can live safely, independently, and with stability.

We provide:

• Waiver Navigation & Access – Assistance with understanding and accessing waiver services, eligibility requirements, and enrollment processes.
   
• Person-Centered Planning – Development of individualized service plans that reflect each person’s goals, needs, preferences, and safety considerations.
   
• Coordination of Supports – Help connecting with approved providers, benefits programs, community resources, and services across systems.
   
• Ongoing Monitoring & Follow-Up – Regular oversight of service delivery to confirm continuity, quality, and timely adjustments as needed.
   
• Advocacy & Rights Support – Support in understanding rights, making informed choices, and securing services consistent with individual preferences.
   

If an individual is transitioning from a facility or institutional setting to community-based living, Vital Community Services assists with a coordinated, seamless transition.

We provide:

• Transition Planning – Assistance arranging safe, stable community housing and coordinating necessary transition activities.
   
• Resource Linkage – Support identifying housing options, discharge planning needs, and required service connections.
   
• Access to Essentials – Help securing equipment, supplies, benefits, and supports necessary to sustain community living.
   
• Stabilization Follow-Up – Ongoing check-ins and coordination to support stability, independence, and reduced risk of readmission.
   

Vital Community Services also supports individuals in building routines, accessing community resources, and developing skills that promote meaningful engagement and independence.

We provide:

• Independent Living Support – Coaching and guidance to build daily living skills and routines.
   
• Community Connections – Assistance connecting to local programs, activities, social supports, and natural community resources.
   
• Life Skills Support – Help with budgeting, scheduling, transportation planning, and personal safety strategies.
   
• Participation & Belonging – Encouragement and coordination for community involvement, natural supports, and social engagement.
   

Vital Community Services collaborates with individuals, families, referral agents, and community partners to ensure clarity, efficiency, and timely coordination. We do not provide direct hands-on nursing or clinical care; instead, we facilitate connections and planning so that individuals can access the supports they need.