Needham, Massachusetts: Anne Dinatale, 60, in her room at Wingate nursing facility. Dinatale was Hillary Tarr, a Community Transitions Case Manager's first case when she started working in the Community Transitions program. Dinatale was admitted to Wingate nursing facility in March of 2015 after being transferred from another nursing facility where she was participating in rehab after a fall in Sept. 2014 in which she fractured the humerus bone in her left arm. Dinatale is battling a number of medical issues, and she needs knee replacements and a right hip replacement. "The list is endless, really," Dinatale said. During their meeting she and Tarr discuss goals for Dinatale to improve her health in order to leave the nursing facility and live on her own in an apartment. Because Dinatale spends all day in bed, she has lost much of the muscle needed to get out on her own. Tarr explains to Dinatale that she must be able to stand and pivot from her bed into a wheelchair and commode, at the very least, in order to live on her own. Once she is able to do that, she will have a better chance of being discharged. Tarr also helps Dinatale with housing applications and has placed her on a waiting list for several locations. "Unfortunately, the typical wait time is two to ten years," Tarr said. Dinatale currently has nowhere to go if she is discharged from Wingate. "“My ex-husband divorced me after almost 40 years. In the beginning it was mind-boggling. He was abusive, so thank God. He sold my house that I grew up in. So I’ve got nowhere to go. I thank God for Hillary. She truly cares. She’s not just going through the motions. She’ll call me if something comes up, she’ll swing by. I don’t know what I would’ve done without her. She just keeps me rolling. Like I say, picture yourself laying in this bed, ya know?" Dinatale said. The walls in Dinatale’s room are filled with various paintings, drawings, and inspirational quotes gifted to her by one of the nighttime supervisors at Wingate who saved the artwork from being thrown out. “I dream of going shopping, setting up my apartment. I dream of nobody coming in in the middle of the night sticking you and moving you. I’ve been waiting so long. And I know it’s a wait, as Hillary prepares me every step of the way. But oh my god, how can you look at these walls for so long? That’s why I started the pictures. I’m much better when I’m looking at a picture and I’m like, “Oh, I’m in the jungle or wherever the picture is,” Dinatale said.