Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. General Factors to Consider for Transition Initiatives


Successful transitions depend fundamentally on the ability to provide services and supports in the community that meet the needs of the person transitioning. Persons leaving ICFs/ID have varying types and levels of need. Residents of nursing facilities are an even more heterogeneous group. Nursing facility residents can include a 75-year-old with cognitive impairment and multiple medical problems, a 45-year-old with quadriplegia, and a 25-year-old with a traumatic brain injury (TBI). While those transitioning will have some needs in common, they will also require services and supports tailored to their specific situations.

Whether a person currently resides in a nursing facility or in an institution serving primarily those with a developmental disability or mental illness, the steps in planning or arranging for home and community services are the same. In either case, solid transitional planning is essential.17 Because each person has unique needs, the complexity and cost of each individual’s transition process will vary. For this reason, it is crucial that states design their transition programs to operate with maximum flexibility. In addition to the numerous options for providing home and community services, Medicaid also provides options to facilitate and support transitions.

The remainder of this chapter will discuss the key factors essential to implementing successful transition programs, along with related Medicaid policies and service options. The key factors are

  • Identifying and addressing administrative and legal barriers to transition.

  • Ensuring the availability of a comprehensive range of home and community services.

  • Developing methods to circumvent HCBS waiver waiting lists.

  • Identifying and educating residents with the desire and the potential for transition.

  • Involving and collaborating with key stakeholders.

  • Developing and implementing care management/service coordination systems that support transition.

  • Identifying and addressing housing needs and rental assistance.

  • Providing flexible funding mechanisms.

States generally undertake many of these activities simultaneously. The chapter ends with a brief discussion of how states can prevent unnecessary admissions to institutions and avoidable long stays.

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