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Long-term care consultation (LTCC)

Page posted: 10/1/03

Page reviewed: 9/28/18

Page updated: 9/28/18

Legal authority

Minn. Stat. §256B.0911


Long-term care consultation (LTCC): A service designed to help people make decisions about long-term care needs and choose services and supports that reflect their needs and preferences.

LTCC team: A multidisciplinary team established by the county board of commissioners or through tribal nation/managed care contracts with DHS. Each local team must include at least one social worker and one nurse. The social worker, public health nurse or registered nurse can provide a component of LTCC and then consult with one another to determine the most appropriate care for the person. Two or more counties/tribal nations may collaborate to establish a joint, multidisciplinary team.


LTCC services:

  • • Ensure people are aware of available home and community-based service (HCBS) options
  • • Prevent long-term placement of people in nursing facilities, hospital swing beds and certified boarding care facilities
  • • Provide options to people so they can make informed decisions about where they want to live and how they can receive needed community supports.
  • Overview

    LTCC includes the following components, which can be provided in any combination:

  • • Face-to-face assessment for home and community-based services (HCBS) programs (e.g., AC and ECS programs, BI, CAC, CADI, DD and EW waivers) (Note: this includes all assessments completed in MnCHOICES and using legacy forms)
  • • Development of a person-centered support plan using the MnCHOICES Support Plan Application, Community Support Plan with the Coordinated Services and Supports Plan, DHS-6791B (PDF) or managed care organization (MCO) equivalent as appropriate
  • • Information/education about and referrals to local, long-term care service options
  • • Information about competitive employment, with or without supports (see CBSM – Employment)
  • • Certain preadmission screenings (PAS) for nursing home admission (see CBSM – OBRA)
  • • Transition assistance to people currently in institutional settings who wish to relocate to community settings (see secondary information).
  • Secondary information

    The LTCC team provides transition assistance to people who request or are referred for assistance and reside in a long-term care facility (e.g., nursing facilities and hospitals).

    Transition assistance services:

  • • Help people determine if they meet criteria to access relocation assistance through CBSM – Relocation service coordination (RSC) or MHCP Provider Manual – Alternative Care (AC) conversion case management
  • • Provide information about the Centers for Independent Living, Disability Hub MN, Senior LinkAge Line® and other organizations that can help with relocation from an institution
  • • Provide information to help people access Minnesota Health Care Programs (MHCP).
  • LTCC transition assistance is different from the formal transitional services available under a waiver. Transition assistance can be provided to anyone who receives LTCC services. For more information about the waiver services, see CBSM – Transitional services – BI, CAC, CADI and DD and CBSM – Transitional services – EW.

    Who can receive LTCC services

    Any person with long-term or chronic care needs can request and is entitled to receive an LTCC service, regardless of his/her age or eligibility for Minnesota Health Care Programs (MHCP). People, families, human services and health professionals or hospital/nursing facility staff may make referrals for an LTCC.

    Non-covered services

    LTCC does not include the following services:

  • • Case management (e.g., case management services billable under relocation service coordination, Rule 185 case management, targeted case management, waiver case management)
  • • Implementation of the support plan (Community Support Plan with the Coordinated Services and Supports Plan, DHS-6791B [PDF] or MCO equivalent)
  • • Other administrative activities (e.g., authorizing, changing and deleting service agreements).
  • Lead agency responsibilities

    County/tribal nation responsibilities

    The county/tribal nation has the following responsibilities:

    1. At an initial request or referral, the county where the person is located must provide an LTCC unless person is:

  • • 65 years or older and enrolled in managed care
  • • Eligible for and choosing to have the LTCC completed through a tribal nation
  • 2. The county/tribal nation must provide an LTCC in an institutional setting when requested

    3. If a person has a history of developmental disabilities or related conditions, the country/tribal nation must refer him/her to the DD screening team for the comprehensive diagnostic determination.

    MCO responsibilities

    If a person is 65 years or older and enrolled in managed care, the MCO is responsible to deliver LTCC services. The MCO may contract with counties, tribal nations or private agencies to deliver these services.

    Who completes assessments

    A certified assessor (see CBSM – MnCHOICES certified assessors) must complete the assessment when using MnCHOICES (see CBSM – MnCHOICES). A member of the LTCC team can complete a legacy assessment.

    LTCC forms

    If a lead agency has not fully implemented MnCHOICES, use the following forms for assessment:

    For forms associated with MnCHOICES, see CBSM – MnCHOICES.

    Assessments and support plans


    For the assessment process, the assessor:

  • • Conducts an in-person visit
  • • Develops the community support plan
  • • Informs the person and/or the person’s legal representative of service options
  • • Helps the person access services.
  • The assessment process identifies the person’s:

  • • Preferences and goals
  • • Strengths and functional skills
  • • Need for supports and services
  • • Informal caregiver supports
  • • Service options and alternatives
  • • Financial resources, including all third-party payers.
  • Community support plan

    The support plan:

  • • Is a written summary of the MnCHOICES or LTCC assessment
  • • Details a person’s strengths, needs, preferences, goals and community support options as assessed.
  • This plan is completed using one of the following:

  • • The MnCHOICES Support Plan Application (see CBSM – MnCHOICES)
  • Community Support Plan with the Coordinated Services and Supports Plan, DHS-6791B (PDF)
  • Community Support Plan, DHS-4166 (PDF) or a similar form developed by the lead agency (e.g., comprehensive care plan).
  • Additional resources

    CBSM – Assessment applicability and timelines

    Other documents

    The county or tribal nation LTCC team must give the person receiving an assessment or LTCC support plan and/or his/her legal representative the following information:

    Managed care organizations provide equivalent information to people using managed care-specific documents.


    Counties/tribal nations

    Assessments or reassessments conducted by counties or tribal nations are reimbursed as an administrative expense through time studies.


    For reassessments conducted by or on behalf of an MCO, see the MCO’s guidance for billing instructions.

    Additional resources

    DD Screening Document Codebook
    Minnesota Centers for Independent Living

    Social Services Time Study Operations and Activity Codes, DHS Bulletin 17-32-08 (PDF)
    Supplemental Waiver PCA Assessment and Service Plan, DHS-3428D (PDF)

    Other CBSM pages

    CBSM – Developmental disabilities screening
    CBSM – Level of care


    Technical guidance

    Instructions for Completing and Entering the LTCC Screening Document and Service Agreement Into MMIS, DHS-4625 (PDF)
    Instructions for Completing and Entering the LTCC Screening Document into the MMIS for the MSHO and MCS+ Programs, DHS-4669 (PDF)

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