Minnesota Minnesota

Moving Home Minnesota Program Manual

Moving Home Minnesota Program Manual

Moving Home Minnesota (MHM) transition planning

Page posted: 5/28/25

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Page updated:

Legal authority

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

Definitions

Transition planning: MHM service a person enrolled in MHM must receive to develop a person-centered transition plan using:

1. MHM Transition Planning Tool (TPT), DHS-6759J.

2. MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K (PDF), which helps transition coordinators address risks when a person does not have another risk mitigation tool.

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. For more information, refer to MHM Manual – Transition coordination.

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).

Overview

Transition planning:

  • · Supports the person to identify their needs for a successful move to the community.
  • · Ensures the TPT addresses what is important to and important for the person.
  • · Clarifies roles and expectations before, during and after the person’s move.
  • · Facilitates a successful, easy move by clearly communicating all key elements of the TPT.
  • · Helps coordinate the person’s supports and services in the community.

    • Eligibility

    A person is eligible to receive transition planning before discharge from the qualified institution if they meet all the following criteria:

  • · Eligible for and enrolled in MHM, as described on MHM Manual – Eligibility.
  • · Maintain enrollment in Medical Assistance (MA) during the time they are eligible to receive MHM services.
  • · Not enrolled in a home and community-based services (HCBS) waiver program, as described on CBSM – Waiver/AC overview.
  • · Want to transition to a qualified community residence, as described on MHM Manual – Eligibility.

    • Covered services

    Transition planning covers:

  • · Completion of the TPT with the person.
  • · Completion of the risk mitigation form with the person if no other risk mitigation tool exists.

    • Non-covered services

    Transition planning does not cover:

  • · Revisions after completion and billing of the TPT. If the transition coordinator needs to update the TPT at a later date, they should bill that time as transition coordination instead. For more information, refer to MHM Manual – Transition coordination.
  • · Planning and services for a person currently receiving relocation service coordination – targeted case management (RSC-TCM) or Housing Stabilization Services (HSS) housing consultation and housing transition services.

    • Transition planning tool (TPT)

    Transition planning is required for MHM participation. The transition coordinator completes the TPT with the person to develop a person-centered transition plan to support the person’s transition to the community. They must complete the TPT up to 180 days before the person discharges from the MHM qualified institution. DHS may approve extensions on a case-by-case basis.

    During completion of MHM TPT, DHS-6759J, the transition coordinator performs the following activities:

  • · Supports a person in a qualified institution to access medical, social, educational, financial, housing and other services and supports needed to move to the community based on the person’s preferences and needs.
  • · Communicates with the person, legal representative (if applicable), informal supports and service providers to develop the TPT.
  • · Coordinates and monitors the implementation of the TPT.
  • · Completes research and make referrals to services and housing.
  • · Travels to conduct an in-person visit with the person and others identified as necessary to develop and implement the goals of the TPT.
  • · Documents and researches transition services that help the person with their rent deposits, utility deposits and moving expenses.
  • · Plans how to support the set-up of the person’s household (e.g., assemble furniture, set up kitchen, stock pantry).
  • · Completes MHM Transitions Worksheet, DHS-6759G to help the person choose a qualified residence.

    • Note: The transition coordinator must update the TPT when there are changes to a person’s transition plan and services throughout their MHM enrollment.

    Risk mitigation and emergency backup planning tool

    Risk assessment is an important part of the transition planning process. To participate in MHM, the person must have a risk assessment, which includes documenting and having a conversation with the person and their support team about:

  • · Potential risk(s) identified through the transition planning process.
  • · Source(s) of those risks.
  • · Alternatives available to address the identified risk(s).

    • If a person will not enroll in an HCBS waiver, the transition coordinator must work with the person, providers and other support team members to complete MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K (PDF) during the transition planning process.

    If a person will enroll in an HCBS waiver, their waiver support plan will address risks, so they do not need to complete DHS-6759K.

    Transition coordinator responsibilities with transition planning

    The transition coordinator is responsible to:

  • · Support the person to make an informed choice in their housing options, transition services and providers.
  • · Complete the TPT and risk mitigation form (if no other risk mitigation tool exists) with the person.
  • · Share the TPT with the person and the supports they identified (paid and unpaid).
  • · Transfer the TPT to the new transition coordinator if the person changes transition coordination providers.
  • · Discuss the moving process with the person and document changes to their support plan.
  • · Follow and review the TPT throughout the person’s transition period.
  • · Update the TPT when necessary.
  • · Sign and keep a copy of the completed TPT in the person’s file.
  • · Complete and maintain documentation in case notes and MHM communication forms that supports and verifies MHM activities.

    • Limitations

    A person can only have one TPT per MHM enrollment span.

    Provider standards and qualification

    Transition planning is provided by a transition coordinator, as described on MHM Manual – Transition coordination.

    Authorization, rates and billing

    Service authorization

    MHM transition planning does not need a service authorization.

    Rates

    The lead agency or provider claims a rate that does not exceed the rate limit in Long-Term Services and Supports (LTSS) Service Rate Limits, DHS-3945 (PDF).

    Billing

    The transition planning provider must deliver this service based on the person's needs and submit claims based on the actual service delivered.

    Additional resources

    MHM Manual – Eligibility
    MHM Manual – Services
    MHM Manual – Transition coordination
    MHM TPT, DHS-6759J
    MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K (PDF)
    LTSS Service Rate Limits, DHS-3945 (PDF)
    MHM SSIS Reference Guide (PDF)
    MHCP Provider Manual – MHM
    CBSM – Person-centered practices

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