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Minnesota Department of Human Services Moving Home Minnesota Program Manual
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Transition Coordinator

Page posted: 1/16/14

Page reviewed:

Page updated: 8/6/14

Legal authority

Deficit Reduction Act, 2005 (PL 109), sec. 6071 (PDF), Patient Protection and Affordable Care Act, 2010 Sec. 2403 (PDF), Minnesota Statutes, section 256B.04, subdivision 20

Definition

Transition coordinator: Helps a participant move from a qualified institution to the community.

Covered services

Transition coordination services are activities that help a person in a qualified institution access medical, social, educational, financial, housing and other services and supports needed so they can move to the community.

Relocation service coordination (RSC) serves as the model for transition services to people enrolled in this demonstration.

Roles and responsibilities

The transition coordinator assures an orderly hand-off to the case manager, community providers, or to the participant to coordinate the community services. The case manager or community provider helps with issues that come up during the year of transition and arrange support the participant in the community.

The transition coordinator will begin meeting with the participant in the institution. Responsibilities include the following:

  • • Facilitates signing of enrollment and informed consent forms
  • • Conducts or arranges, within 30 days of assignment, a person centered assessment using the most current assessment protocol
  • • Leads the transition planning process
  • • Develops an individualized person-centered transition plan
  • • Assists participants with completing the Moving Home Minnesota Transition Planning Tool, DHS-6759J (PDF) and, if necessary, the Moving Home Minnesota Transition Planning Tool (Part 2): Risk mitigation and emergency backup planning, DHS-6759K (PDF)
  • • Works with the housing specialist to locate housing
  • • Works with the Disability Hub MN to identify appropriate employment supports (if necessary)
  • • Sets up transportation to look for housing and/or employment for participant
  • • Coordinates details to set up home for participant
  • • Coordinates meetings, medical follow up appointments, delivery of medical equipment, etc.
  • • Conducts a risk assessment and risk mitigation plan for living in the community
  • • Arranges a “warm hand-off” to the community case manager if different from the transition coordinator
  • • Coordinates day of discharge
  • • Assures medications, required services are in place
  • Note: Transition coordinator or case manager is present the day of the move.

    Risk assessments

    Risk assessment is an important part of the transition planning process. It is a requirement to participate in Moving Home Minnesota.

    When no other risk mitigation tool is in place, the transition coordinator and the participant must complete the risk mitigation plan, Moving Home Minnesota Transition Planning Tool (Part 2): Risk mitigation and emergency backup planning, DHS-6759K (PDF) documents a conversation where the participant and/or his/her legal representative review:

  • • The potential risks identified through the assessment and transition planning process
  • • The source of those risks
  • • The alternatives available to address the risks identified.
  • Institutionalization

    When people return to the community after an institutionalization and continue their enrollment in the demonstration, they need an assessment for a new level of care.

    The risk assessment and risk mitigation plan should be reviewed and adjusted to reflect any changes in risk or risk mitigation.

    Qualifications of a transition coordinator

    A lead agency (county or tribe), managed care organization, contracted or enrolled provider may provide transition coordination services (Minn. Stat. §256B.0621)

    Depending on the age and circumstances, a participant may choose one of the following to be the transition coordinator:

  • • County case manager
  • • Developmental disability case manager
  • • Mental health case manager
  • • Managed care organization coordinator
  • • Relocation service coordinator
  • Additional resources

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