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Keeping Coloradans in the Community and out of Long-Term Institutionalization

For Members     Stakeholder Engagement     Contact Us

Since its inception, the primary focus of the Office of Community Living (OCL) has been and continues to be supporting Health First Colorado members to remain in their homes and the broader community. While living in an institutional setting such as a nursing facility is a much-needed and sometimes necessary option for a small subset of members, OCL is dedicated to ensuring that everyone has every opportunity to live in the community of their choosing. 

As a part of OCL’s dedication to this vision, key goals have been accomplished in recent years. Specifically, HCPF has received budget and legislative authority for a multitude of programmatic and policy improvements as well as the approval of a new $43M federal Money Follows the Person Demonstration grant. This funding, in addition to funding received during the 2023 legislative session, will help invest over $100M into the Home and Community Based Services (HCBS) system in Colorado over the next 4 years.

These investments are over and above the $550M currently dedicated to enhancing, expanding and strengthening the state’s HCBS system through the American Rescue Plan Act (ARPA). 

  • 200 new housing vouchers were made available for institutional transitions and at-risk population members
     
  • 200 more vouchers will be available starting July 1, 2024
  • Housing navigation will be available to the at-risk population which will strengthen the relationship between housing and healthcare by helping these members find affordable and accessible housing options

  • Informational Memo IM 24-007- Minimum Data Set (MDS) Section S and Q Administration - March 6, 2024
    • The purpose of this Informational Memo is to inform nursing facility staff who complete MDS and Local Contact Agencies (LCAs) of operational instructions related to the Minimum Data Set (MDS) section Q and MDS Section S added in October 2023.
       
  • Operational Memo OM 23-048 - Group In-Reach in LTC Nursing Facilities for Medicaid Members - July 31, 2023
    • The purpose of this Operational Memo is to inform Nursing Facilities of the Group In-Reach program and how Nursing Facilities can support the implementation of this program. The program is designed to provide our Long-Term Care (LTC) Medicaid Members currently residing in a Nursing Facility, with a brief meeting regarding transition and community-based services in a group setting.
       
  • In-Reach Counseling
    • Group In-Reach includes actively connecting with members who are living in nursing facilities or other institutions and helping them make an informed choice about transitioning out of the nursing home to live at home or elsewhere in the community. All members have the right to be informed about their options to live at home or in the community while still receiving the care and services they need and decide if transitioning is right for them.
       
    • Group In-Reach provides:
      • Information about housing and other services in the member's community that may be available to them as an alternative to living in the nursing facility
      • Answers to any questions or concerns members, their families, or caregivers may have
      • Assistance with connecting members with Case Management Agencies, Transition Coordination Agencies, or other organizations that can help set up services to meet the member's specific care needs while living in the community
         
    • HCPF started Group In-Reach counseling meetings in August 2023
      • The In-Reach team has completed Group In-Reach in 82% of all nursing facilities in Colorado
      • The In-Reach team has worked with 126 members and completed 64 referrals for Transition Services as of September 2023
      • Individual In-Reach counseling will be made available to members living in nursing facilities in the summer of 2024
         
  • At-Risk Population Outreach
    • HCPF is working to identify members living in the community who are at the highest risk of needing institutional care. Plans are in development to conduct additional outreach to support these members in the community with services and necessary supports prior to their need for institutional admission.

  • View ARPA 5.02 - Improve & Expedite Long-Term Care Eligibility Processes
     
  • Presumptive Eligibility for people with disabilities will be implemented to bridge the gap to Long-Term Services and Supports (LTSS) and budget authority was approved through HCPF’s FY 2023-24 BA-07 request.  Additional state and federal approval will likely be needed for implementation.
     
  • A contract for Long-Term Care financial eligibility escalations will be executed in Fall 2023 to expedite the financial eligibility process and give members access to services more timely.

  • Provide an increase to the maximum allowed for transition set-up costs from $1,500 to $2,000 per transition
     
  • Increase the maximum allowed for Targeted Case Management-Transition Coordination from 240 units to 360 units  (1 unit = 15 minutes)
     
  • Rapid Reintegration
    • Changes to the current case management system are presumed to decrease the length of time a member who is interested in living in the community will live in a nursing facility before transition services are offered. 
    • Rapid Reintegration plans to address barriers, needs, and supports a member has prior to transitioning into the community to decrease rates of reinstitutionalization due to health and safety concerns.
       
  • Alignment of home modification policy across all waivers which provides a reset to the individual limit with the renewal of the HCBS waiver

  • A new $43M federal Money Follows the Person (MFP) Demonstration grant will make Targeted Case Management-Transition Coordination available to members for a year following discharge
     
    • The MFP Demonstration grant includes the following supplemental services:
       
      • Environmental Adaptations to provide home modifications prior to discharge
        • Allows a member to enhance accessibility to their home through modifications such as widened doorways, the construction of ramps, or adaptations to the bathroom or kitchen
           
      • Peer mentorship prior to discharge
        • Provides members with support from someone with lived experience to build awareness of resources available to assist with community living
           
      • Short-term rental assistance
        • Provides members with rental support including rental arrears, utility start-up costs, security deposits, etc.
           
      • Pre-tenancy support
        • Helps members learn about the requirements to access and maintain community housing
           
      • Short-term food assistance
        • Provides members with payment for food pantry items for up to 30 days following discharge
           
    • The MFP Demonstration grant accompanies the release of an MFP Community Capacity Building grant created by OCL to support organizations that provide transition services and supports

  • HB 22-1302 provided HCPF the ability to hire 12 new full-time employees and contractor resources to improve processes for members attempting to receive long-term care in the community. The Compliance and Innovation Division was created within the Office of Community Living in August 2022 and provides oversight to Transition Coordination, Housing Navigation, In-Reach Counseling, Pre-Admission Screening and Resident Review (PASRR) program, Money Follows the Person, and more.

For Members

​ Request Information About Transitioning to Live in the Community

What can Transition Services do for me?

  • Help you determine if transition to a community-based setting is possible
  • Help coordinate your transition into a community-based setting
  • Enhance and improve your quality of life
  • Improve your access to an array of Home and Community Based Services (HCBS)
  • Increase housing options for people with all types of disabilities

Note: Referral to Transition Services does not guarantee transition into a community-based setting

 

Who Qualifies?

  • You must be a Health First Colorado (Colorado's Medicaid Program) member
  • You must be 18 years of age or older
  • You must qualify for an HCBS waiver
  • You must reside in a qualified institution, which is:
    • a nursing home, or
    • an intermediate care facility for people with intellectual disabilities
  • You may also receive expanded HCBS services if you reside in the community and have a qualifying life event

Benefits and Services


See other State Plan Benefits

Transition Services Flyer - Updated July 2024

View Long-Term Services and Supports (LTSS) General Brochure

HCBS Services

These HCBS services on the following waivers are available to you:

 

Expanded Home and Community-Based Services

As of 2019, the following home and community-based services are available to you:

Community to Community Transition Fact Sheet - August 2022

 

How do I get started?

Referrals to options counseling can be made by:

  • Long-Term Care Facility staff
  • Family members
  • Friends
  • Community members
  • Self

Contact the Local Contact Agencies for Options Counseling in your area to make a referral for yourself or someone else who may desire to learn about community living options.

Program Contacts

Contact the Local Contact Agencies for Options Counseling in your area to make a referral for yourself or someone else who may desire to learn about community living options.

Provider and Case Manager Support Resources

 

Department Contacts

Matt Bohanan - Access Unit Supervisor
Contact for programmatic questions
Matthew.Bohanan@state.co.us
303-866-5331

Nora Brahe - Transitions Administrator
Contact for community transition information or with questions about the member transition process
Nora.Brahe@state.co.us
303-866-3566

Courtney Thomason - Colorado Department of Local Affairs - Division of Housing
Contact for Transitions Services related housing questions, and housing voucher process and administration
Courtney.Thomason@state.co.us
303-864-7831

How can I participate with other stakeholders on programmatic and policy issues related to Transition Services?

 

Return to:

Questions?  Contact hcpf_accessunit@state.co.us

Stakeholder Engagement

 

Stakeholder Feedback Survey - help us continue to prioritize this important work

Operational Memo OM 23-048 - Group In-Reach in LTC Nursing Facilities for Medicaid Members - July 31, 2023

  • The purpose of this Operational Memo is to inform Nursing Facilities of the Group In-Reach program and how Nursing Facilities can support the implementation of this program. The program is designed to provide our Long-Term Care (LTC) Medicaid Members currently residing in a Nursing Facility, with a brief meeting regarding transition and community-based services in a group setting.

Public Meetings

Reasonable accommodations will be provided upon request for persons with disabilities. Auxiliary aids and services for individuals with disabilities and language services for individuals whose first language is not English may be provided upon request. Please contact John.R.Barry@state.co.us or 303-866-3173, or the 504/ADA Coordinator at hcpf504ada@state.co.us at least one week prior to the scheduled meeting to make arrangements.
 

Contact Us

HCPF_AccessUnit@state.co.us


Money Follows the Person page

Other Stakeholder Engagement Opportunities

Long-Term Services and Supports Programs page