After Medicaids enactment, the following decades saw an increase in the number of states developing alternatives to institutional care for persons with disabilities, in order to provide services and supports in the most integrated setting appropriate to their needs. The Supreme Court decision--Olmstead v. L.C., finding that unnecessary segregation of people with disabilities in institutions constitutes a form of discrimination under the Americans with Disabilities Act (ADA)--gave legal weight and new urgency to this policy direction.2 The Centers for Medicare & Medicaid (CMS) guidance, issued to states in January 2000, underscores the importance of states efforts to move people out of nursing homes and other long-term care institutions into community settings as a part of a states comprehensive effectively working plan for providing services to qualified persons in the most integrated settings. (See the Resources section of this chapter for a link to the complete text of this guidance.)
Transitioning people with disabilities from institutions to the community began in a serious way with the recognition that many people with intellectual disabilities and other developmental disabilities (ID/DD, hereafter called developmental disabilities) were inappropriately placed in large public facilities and institutions. This recognition, starting in the 1970s, led to successful efforts by many states to sharply reduce the number of people living in large institutions (16 or more beds) by transitioning residents to a range of smaller, community settings. This dramatic wave of deinstitutionalization set in motion the realignment of state ID/DD service systems from institutionally dominated to community-centered.
The first section of this chapter provides a brief overview of the transition process for residents of ICFs/ID, distilling the lessons learned from this experience that apply to transition initiatives more generally. The second section focuses on current Medicaid options for supporting transitions and discusses major factors states need to consider when setting up transition programs--focusing primarily on the transition of nursing home residents--but also applicable to transitions from ICFs/ID and other institutions.