Transition Management

Provides relocation assistance and intensive service coordination activities to assist NF, hospital, IMD, and ICF/IID residents to transition to community settings of their choice. Transition managers provide oversight and coordination activities for participants during a transitional period up to twelve (12) months following a return to the community, functioning as a liaison between the participant, institutional or facility discharge staff, and other individuals identified by the participant. Participants are eligible to receive transition management when planning to discharge from a qualifying institution after residing within that institution for a minimum of forty-five (45) days. (7-1-26) 01. Provider Qualifications. Transition managers must: (7-1-26) a. Successfully complete of a Department-approved Transition Manager training prior to providing any transition management or transition services; (7-1-26) b. Have a Bachelor's degree in a human services field or three (3) years' supervised work experience with the population served; and (7-1-26) c. Be employed by an agency. (7-1-26) 02. Service Description. Includes the following activities: (7-1-26) a. A comprehensive assessment of health, social, and housing needs; (7-1-26) b. Development of housing options, including assistance with housing choices, applications, waitlist follow-up, roommate selection, and introductory visits; (7-1-26) c. Assistance with tasks necessary to accomplish a move from the institutional setting; (7-1-26) d. Securing Transition Services to coordinate the move, including: (7-1-26) i. Obtaining DME, assistive technology, and medical supplies; (7-1-26) ii. Arranging for home modifications; (7-1-26) iii. Applying for public assistance; or (7-1-26) iv. Arranging household preparations including scheduling moving or cleaning services, utility set-up, IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 550 Page 127 purchasing furniture, and household supplies. (7-1-26) e. Coordinating with others involved in plan development for the participant to ensure successful transition and establishment in a community setting; and (7-1-26) f. Providing post-transition support, including assistance with problem solving, dependency and isolation concerns, consumer-directed services and supports, post-secondary educational institutions and proprietary schools, and community inclusion. (7-1-26) 03. Limitations. Transition management is limited to seventy-two (72) hours per participant per qualifying transition. (7-1-26) SUB AREA: PERSONAL CARE SERVICES (PCS) (Sections 550-559)