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

• 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
  • Dept. of Local Affairs (DOLA) FY 2023-34 R-1
     
• 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

In-Reach Team Project Feedback Form - Submit feedback regarding At-Risk Diversion, Group In-Reach, Individual In-Reach, and Rapid Reintegration projects

• 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 its implementation. 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 Diversion
  • HCPF, in collaboration with stakeholders, has developed a new process through which supports and services are arranged and/or provided to Health First Colorado Medicaid member(s) most at risk for admission to an institution or an institution-like setting. In 2022, HCPF began discussions, providing updates, and receiving feedback from stakeholders regarding where improvements to our long-term care system would benefit our members most.
  • At-Risk Diversion is aimed at strengthening community-based services for people with disabilities, enhancing home and community-based services to expand access, improve quality, and streamline eligibility to ensure all individuals can receive care in their communities. The new process will include targeted outreach to Medicaid members living in the community who are at the highest risk of needing institutional care.
  • In 2023, HCPF began researching a variety of models and different factors that could be tested. The Department reviewed published articles and studies that were used to identify variables and methodologies. Also, HCPF researched other state activities that may align with the goal of the at-risk work in Colorado. Through research and testing, the chosen model generated a list of members with the highest risk for nursing facility admission based on their risk score and it included certain characteristics, diagnoses, and/or behavioral needs.
     
  • View Informational Memo IM 24-027 - At-Risk Diversion - October 21, 2024
    • The purpose of this Informational Memo is to inform Case Management Agencies (CMAs) of updates related to the implementation of At-Risk Diversion, including upcoming training opportunities.
       
• At-Risk Target Population
  • HCPF was able to develop a model to determine certain characteristics, diagnoses, and/or behaviors that may lead to an individual's admission into a nursing facility. The identification of At-Risk members will include but is not limited to age, lack of support, previous nursing facility admission(s), multiple hospital admissions, chronic conditions, or mental/behavioral health conditions. 
  • The population may change based on member needs and stakeholder feedback; changes will be posted to this page for transparency.  
  • The At-Risk Target Population is enrolled in Health First Colorado Medicaid and that is identified as At-Risk for institutionalization.
    • Resides outside of a nursing facility or other institution-like setting
    • Adults, over the age of 21
    • Diagnosed with a physical disability (can include the presence of a co-occurring disability)
       
• At-Risk Outreach
  • Medicaid members who have been identified as At-Risk will receive targeted outreach to offer additional support, services, resources, and education to support these members in the community with services and necessary support before a need for institutional admission. At-Risk Diversion is optional, and the member can opt-out or decline At-Risk support at any time. At-Risk Diversion will include support from Case Management Agencies (CMA), Regional Accountable Entity (RAE) regional organizations, and Targeted Case Management-Transition Coordination (TCM-TC).
    • Case Management Agency (CMA) is a public, private, or non-governmental non-profit Agency that meets all applicable state and federal requirements and is certified by HCPF to provide Case Management services for Home and Community-Based Services (HCBS) waivers. For more information visit the Case Management website.
    • Accountable Care Collaborative (ACC) is Health First Colorado (Colorado's Medicaid program). Health First Colorado contracts organizations in each region of the state to manage both physical and behavioral health care. This organization is called a Regional Accountable Entity (RAE). Care Coordination is available in every regional organization. For more information visit the Health First Colorado website.
    • Targeted Case Management -Transition Coordination means a public, private, or non-governmental non-profit Agency that meets all applicable state and federal requirements and is certified by HCPF to provide Transition Coordination services and support for members moving from a congregate setting other than an assisted living facility or being diverted from possible institutionalization.  For more information view the Targeted Case Management-Transition Coordination Billing Manual. 
       
• Upcoming Key Dates and Milestones
  • At-Risk Diversion begins January 31, 2025
     
• More Information
  • HCPF has been diligently working on ensuring system changes are complete and fully functional before implementation.
  • HCPF will continue to prioritize this important work and obtain feedback from participants, providers, and all other interested Stakeholders. 
    • The In-Reach Team Project Feedback form is available to provide individuals, agencies, and other Stakeholders with an opportunity to provide feedback, ask questions, and report issues and/or concerns outside of traditional meetings. 
    • HCPF will provide training, host open office hours, and will have an escalation team to provide oversight and address questions, issues, and concerns. 
    • Informational documents will be posted online when available.
  • For more information on Transition Services and benefits visit the Transition Services website.
  • For more information on benefits, programs, and projects relating to long-term services and support programs (LTSS) for people with disabilities and older adults in Colorado visit the Long-Term Services and Supports Program website.
     
• In-Reach Unit Contact
  • Email hcpf_clo_inreach@state.co.us for questions about At-Risk Diversion, Group In-Reach, Individual In-Reach, and Rapid Reintegration

• View CFC Home Page

• 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