Deficit Reduction Act, 2005 (PL 109) §6071 (PDF), Patient Protection and Affordable Care Act, 2010 §2403 (PDF), Minn. Stat. §256B.04, subd. 20

Transition coordination: MHM service that provides coordination of activities to support a person who resides in a qualified institution to gain access to medical, social, education, financial, housing and other services and supports that are necessary to move to the community.

Transition coordinator: Professional who carries out the transition coordination service and supports a person to move from a qualified institution to the community with MHM.

Lead agency: County, tribal nation or managed care organization (MCO).

A person is eligible to receive MHM transition coordination if they meet the criteria on MHM Manual – Eligibility.

MHM transition coordination includes, but is not limited to the following activities:

MHM transition coordination services do not cover:

For a person who chooses to move to a different state, transition coordination services may be covered up to the date of the person’s move and if the person both:

If the other state participates in the Money Follows the Person (MFP) program, it is the transition coordinator’s responsibility to notify that state’s MFP staff to determine if the person chooses and may receive MFP community services.

The transition coordinator begins transition coordination by meeting with the person in the institution.

The transition coordinator is responsible to:

1. Facilitate the completion and submission of MHM Intake Form, DHS-5032 if not already done.

2. Lead the transition planning process once the lead agency confirms the person is approved for MHM (refer to MHM Manual – Lead agency responsibilities).

3. Complete and keep on record the following forms:

4. Maintain routine contact, communicate and/or travel to visit with the person or others identified as necessary to develop and implement the goals of the transition plan.

5. Coordinate and monitor the overall implementation of the TPT.

6. Work with the DHS MHM housing specialist to help the person locate affordable 811 project-based rental assistance (PRA) supportive housing, if appropriate.

7. Work with Disability Hub MN to identify appropriate employment supports if necessary.

8. Set up transportation so the person can search for housing and/or employment.

9. Report assurance of qualified residence to DHS. For more information, refer to the communication with DHS section lower on this page.

10. Coordinate with the discharge planner at the qualified institution.

11. Coordinate details to set up the person’s home.

12. Coordinate meetings, medical follow-up appointments, delivery of medical equipment, etc.

13. Arrange a smooth transition with the community case manager (if different from the transition coordinator), which includes the following activities:

14. Coordinate the person’s day-of discharge activities.

15. Ensure the person’s medications and required services are in place.

16. Report the person’s confirmed move to DHS. For more information, refer to the communication with DHS section lower on this page.

Pre-transition communication

The transition coordinator must submit MHM Communication Form, DHS-6759H to DHS in the following situations:

Post-transition communication

When the person has transitioned successfully to the community, the transition coordinator must submit MHM Communication Form, DHS-6759H to DHS. Use the “Participant has transitioned to the community” reason for communication and provide the information requested on the form. DHS will use this information to update MMIS with the date the person moves into a qualified residence to allow claims to pay. The person’s move-in date is the start date for their 365/366-day period of MHM community-based services eligibility.

Additional communications

Transition coordinators must submit MHM Communication Form, DHS-6759H to DHS in the following situations:

DHS may grant extensions to the 180-day transition planning and transition coordination eligibility span on a case-by-case basis. The transition coordinator may request an extension by submitting MHM Communication Form, DHS-6759H. Use the “Transition Coordinator Extension Request” reason for communication.

The transition coordinator must:

Transition coordination is limited to pre-transition services up to the day the person moves to the community.

A provider cannot deliver transition coordination to more than one person at the same time.

A person cannot receive MHM transition coordination if they also receive RSC-TCM or HSS housing transition.

Transition coordination can be provided by a lead agency or a DHS-approved provider who meets the relocation targeted county case management provider qualifications per Minn. Stat. §256B.0621.

License requirements

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

DHS-approved transition coordination providers must complete HCBS Programs Service Request, DHS-6638 (PDF) and MHM – Transition Planning, Transition Coordination and Demonstration Case Management – Provider Assurance Statement, DHS-3879 (PDF) either online through the Minnesota Provider Screening and Enrollment (MPSE) portal or fax the forms to MHCP Provider Eligibility and Compliance at 651-431-7493.

Background studies

Minn. Stat. Ch. 245C requires a licensed program to conduct background studies. Providers who have direct contact with the person must have a completed background study (for a complete list, refer to Minn. Stat. §245D.03). A provider must complete and submit individual background studies using New Electronically Transmitted Study (NETStudy) through DHS licensing.

Service authorization

MHM transition coordination does not need a service authorization.

Rate

The lead agency or provider claims the actual 15-minute units provided. The transition coordination rate cannot exceed limit in the Long-Term Services and Supports (LTSS) Service Rate Limits, DHS-3945 (PDF).

Billing

The transition coordination provider must plan and deliver services based on the person’s needs as documented in the person’s TPT. All submitted claims must be based on actual services delivered.

The transition coordination provider cannot bill services based on an average of billing units provided to a person.