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What is Pathways to Community Living?

Pathways (Money Follows the Person) transitions interested and qualified Oklahomans from a nursing home or rehabilitation center back into the community of their choice. Pathways also helps establish sustainable and culturally appropriate long-term services and supports in tribal communities. 

Tribal Benefits

  • Promotes government-to-government relationships
  • Enhances tribal infrastructure
  • Increases access to needed long-term services
  • Addresses disparities
  • Supports effective tribal programs
  • Maximizes fiscal resources

Who Qualifies?

Members of federally recognized tribes in Oklahoma may be eligible if they meet the following criteria:

  • 19 years old and older
  • Lived for more than 60 days in an inpatient facility (nursing or intermediate care)
  • Interested in moving back to the community
  • Eligible for Sooner Care at least one day before leaving the inpatient facility 

Covered Services

Final services will be determined in consultation with the participating tribes but may include:

  • Personal care
  • Skilled nursing
  • Case management
  • Adult day services
  • Transportation
  • Home-delivered meals
  • Limited dental services
  • Mental Health Counseling
  • Self-direction for services
  • Transition funds for housing needs

Our Mission

To provide states and tribal partners with the opportunity to create and implement tribally sustainable home and community-based long-term services and supports systems.


  • Expand the leadership role of tribes in the creation, implementation and operation of Medicaid-funded programs tailored for tribal members
  • Transition eligible and interested tribal members from inpatient institutional settings back into their homes or communities

For more information

Johnney Johnson

Carley Fryrear 
Community Outreach Coordinator

LeeAnn Bennett
Community Outreach Coordinator

Last Modified on Apr 26, 2023