As the Local Contact Agency (LCA), DOM has the responsibility of ensuring that individuals in nursing facilities who express a desire to talk with someone about the possibility of returning to the community are provided timely information about available options, and supports for community living and to support individual choice.
Transition to Community Referral Process
DOM is the designated LCA to support the resident’s expressed interest in being transitioned from the Nursing Facility to community living. Once DOM has been notified of the resident’s request, information about community living options and available supports and services will be provided to the resident or their responsible party.
Nursing Facility Responsibility:
A. Obtain agreement and permission from each individual resident, through the usual signed release of information form, in order to send that individual’s name to DOM for referral to community resources.
B. Division of Medicaid Transition to Community Referral (TCR) form must be submitted to DOM within 10 business days of a “yes” response to item Q0500B of the MDS 3.0. The interactive TCR form should be completed and submitted. The online TCR form is available below.
C. If contact has not been made with the resident or responsible party by telephone or in person within 10 business days, a follow up should be made as necessary. Follow up contact information:
A. As the local contact agency, all TCR referrals will be received by the Office of Community-Based Services and a determination of program referral and/or community support services will be made within one to three business days of receipt. The date will be recorded and starts the timed process.
B. DOM will maintain a Transition to Community referral tracking system.
C. Educational packets and training regarding community resources will be provided to nursing facilities, agencies and organizations to help facilitate this process.
Referral Agency Responsibility:
A. The Referral Agency will contact the individual or the responsible party by phone within five business days.
B. Will provide the individual with information about services and/or resources in the community.
C. Nursing facility residents who qualify for waiver services should be given priority or placed at the top of the waiting list when there are no current resources available (slots) if:
- their nursing facility stay is greater than 90 days and
- Medicaid has paid for at least one day of the nursing facility stay.
D. Referrals not meeting the above criteria should be contacted and placed on the referral/waiting list.
E. Once the disposition determination has been made the Referral Agency will submit the DOM TCR form by:
If there is no determination by the 16th day from receipt of the referral, DOM must receive a notification of progress.
Transition to Community Referral Form
To access and submit a referral, click on the “TCR Form” link below and follow the instructions for completing the form.
Transition to Community Referral Form Instructions
- Date of Admission – original admission date to this facility
- Referral Date – date the N.F. received a request from the resident to speak to someone about the possibility of returning to the community (send to DOM within 10 business days)
- Referred By – name of person completing and submitting form, their phone number and email address
- Facility Name – the Resident is currently there
- Resident Name, DOB xx/xx/xxxx – and identifying information if they have Medicaid, Medicare or Social Security
- Contact Name – of significant other, guardian, or legally authorized representative, phone number and relationship
- County of Resident’s transition – to aid in referral selection
- Mark the box for services – that the Resident will need at home or specify any other needs
- Based on Medicaid Waiver criteria – if resident has Medicaid, check which of these programs they would qualify for or list any previous waiver services
- Print Form then Submit by Email – after completing the form you may print it for your records then click submit button at bottom of form to send to DOM.
Transition to Community Referral Resources
Transition to Community Referral Contacts
For more information or if you have problems with form submission, contact Community-based Services by: