Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Developing and Implementing Case Management/Service Coordination Systems That Support Transition


The primary service needed to ensure a successful transition is case management, also called care management, service coordination,transition coordination, or relocation assistance. In general, individuals with severe disabilities and medical needs who have no informal care will require more intensive case management than those with lesser needs. Individuals without their own or family housing in the community will also require assistance in finding affordable and accessible housing.

Transition case management is an intensive process that includes a range of activities: identifying and coordinating services, motivating participants, working with participants’ families or friends, assisting participants in finding housing and other resources, and assessing participants’ living arrangements for health and safety issues. The use of a person-centered planning format--one that involves all stakeholders in the transition--enables the development of a cohesive transition and service plan, which is essential to successful and safe transitions. With regard to specific case management practices, having transition staff present on the day of relocation can help to ensure a smooth transition.

Medicaid allows states to pay for case management services related to transitioning an individual from an institution, as long as they do not duplicate regular discharge planning services paid for through Medicaid or another source. Medicaid-reimbursable case management services that help to ensure a successful transition include the following:

  • Discussing options with the resident.

  • Arranging visits to potential settings and assisting the resident to obtain essential furniture and household items.

  • Providing education and training for the resident prior to discharge.

  • Arranging transportation on moving day.

  • Implementing a plan of care so that services are available immediately when the individual moves.

Three options are available for obtaining Medicaid reimbursement for case management services: case management as a waiver service, the targeted case management option, and administrative claiming.31 (The advantages and drawbacks of each of these payment methods are described in Chapter 4.)

The targeted case management option is likely to offer the most flexibility because it can be targeted specifically to persons who are being transitioned. The Federal statute defines targeted case management as “services which assist an individual eligible under the plan in gaining access to needed medical, social, educational, and other services.” This definition enables states to coordinate a broad range of activities and services outside the Medicaid program, which are necessary for the optimal functioning of a Medicaid beneficiary in the community. State Plan targeted case management services must include the following four components: assessment of need, plan of care development, referrals and linkages, and monitoring and follow up activities. States desiring to provide transition case management services under the targeted case management option may do so by amending their State Plans accordingly. If a state does not plan to offer the service to all Medicaid recipients, the amendment must specify precisely the group or groups to be served.

CMS policy regarding case management services specifically recognizes that some individuals may require a considerable amount of time to transition to the community. It is possible to obtain Medicaid funding for case management services provided during the last 180 consecutive days of a Medicaid-eligible person’s institutional stay, if provided for the purpose of community transition. When case management services are provided under the targeted case management option, states may specify a shorter time period or other conditions under which the services may be provided.32

Case management furnished as a service under an HCBS waiver program may also be provided to institutionalized persons during the last 180 consecutive days prior to discharge. However, Federal financial participation (FFP) is available only on the date the person leaves the institution and is enrolled in the waiver. In these cases, the cumulative total amount paid is claimed as a special single unit of transitional case management. (See the Resource section of this chapter for a link to CMS State Medicaid Director letters providing guidance on this topic.)

Although Medicaid policy regarding case management is flexible and allows payment for services over a 6-month period, states need to ensure that the amount of case management it covers is sufficient--particularly for nursing home residents who lack housing, have weakened community connections, or are dependent on the institutional environment. In such instances, the individual’s needs may exceed case managers’ ability and time to provide the services needed. States need to ensure both a sufficient number of case managers and sufficient time for them to complete complex transitions.

Connecticut funds six full-time transition coordinators to provide outreach and transition services, and a toll-free line for nursing facility residents that gives them direct access to a transition coordinator.

Ensuring adequate transition capacity may require education and training for hospital and nursing home discharge planners, nursing facility staff, and community case managers about home and community services, generally, and nursing facility transition, specifically.

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