At-Risk Diversion Transition Escalations Rapid Reintegration Contact Us
The Department of Health Care Policy and Financing (HCPF), in collaboration with stakeholders, is in the process of developing and implementing programs to improve transition and diversion efforts. Diversion and Rapid Reintegration will provide At-Risk population members with education, available resources, support, community-based services, and information regarding community-based living options. Escalations will manage transition escalations, complaints, monitor and resolve problems that arise during transition planning and diversion planning.
We will continue to prioritize this important work and obtain feedback from participants, providers, and all other interested stakeholders. We will utilize this website to provide updates as they become available, in addition to information about future opportunities for stakeholder engagement, training, and open office hours. We will have an escalation team to provide oversight and address questions, issues, and concerns.
At-Risk Diversion
HCPF, in collaboration with stakeholders, has developed a new process through which supports and services are arranged and/or provided for Health First Colorado (Colorado's Medicaid Program) member(s) most at risk for admission to a nursing facility. At-Risk Diversion is aimed at strengthening community-based services for people with disabilities, enhancing home and community-based services to expand access, and providing access to housing supports to ensure individuals can receive care in their communities. The new process will include targeted outreach to Health First Colorado members living in the community who are at the highest risk of needing institutional care.
- View Operational Memo OM 25-002 - At-Risk Diversion Process - January 2, 2025
- Informs Case Management Agencies (CMAs), Home and Community-Based Services (HCBS) members, their families, and other interested stakeholders of the forthcoming implementation of At-Risk Diversion, outreach to HCBS members who may be most at-risk of nursing facility admission, and provide CMAs the operational guidance necessary to implement At-Risk Diversion. This memo outlines CMA roles and responsibilities, clarification on outreach, and documentation requirements.
- Informs Case Management Agencies (CMAs), Home and Community-Based Services (HCBS) members, their families, and other interested stakeholders of the forthcoming implementation of At-Risk Diversion, outreach to HCBS members who may be most at-risk of nursing facility admission, and provide CMAs the operational guidance necessary to implement At-Risk Diversion. This memo outlines CMA roles and responsibilities, clarification on outreach, and documentation requirements.
- 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.
- 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 Diversion FAQ - January 2025
At-Risk Target Population
- HCPF researched a variety of models and tested different data factors to identify individuals most at risk of nursing facility admission. HCPF surveyed stakeholders, reviewed published articles and studies, researched other states’ programs, and conducted statistical analysis to identify different variables and methodologies to use. The initial model generated a list of members most at-risk for nursing facility admission through a risk score based on certain characteristics, diagnoses, and/or behavioral needs.
- The identification of At-Risk members will include but is not limited to age, whether or not someone has a partner, previous nursing facility admission(s), inpatient hospital admissions, chronic conditions, or mental/behavioral health conditions.
- The minimum At-Risk Target Population criteria include Health First Colorado members who are:
- Residing outside of a nursing facility or other institution-like setting
- Adults over the age of 21 years old
- Diagnosed with a physical disability (can include the presence of a co-occurring disability)
- The target population may change based on member needs and stakeholder feedback; changes will be posted to this page for transparency.
- Note: Because this initiative is also an integral part of the Department of Justice Settlement Agreement, the model to identify members most at-risk has to be approved by the Agreement Monitor. Additional information and updates will be posted, when available.
- HCPF is working through that process while also rolling out the initial model to pilot the outreach efforts.
- HCPF is working through that process while also rolling out the initial model to pilot the outreach efforts.
- View the Methodology Development for Identifying At-Risk Members for more about the modeling process.
At-Risk Outreach
- Health First Colorado 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 will include support from Case Management Agencies (CMA), Regional Accountable Entity (RAE) organizations, and Transition Coordination Agencies (TCA). As part of this outreach, CMAs and RAEs will complete an At-Risk Assessment with members to determine any factors that put them most at risk of nursing facility admission and identify community-based resources to support them.
- A 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 Agency Directory page.
- A Regional Accountable Entity (RAE) is an organization in each region of the state contracted by HCPF to provide care coordination and manage both physical and behavioral health care. For more information visit the Health First Colorado - Regional Organizations page.
- A Transition Coordination Agency (TCA) 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 Targeted Case Management and Transition Coordination (TCM-TC) 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 visit the Transition Services Resources page.
- A 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 Agency Directory page.
- At-Risk Diversion is optional and the member can opt-out or decline At-Risk support at any time.
- View the At-Risk Assessment by Case Managers and Care Coordinators for more information.
Transition Escalations
How to Submit a Transition Escalation via Salesforce Ticket
- Complete the Webform to begin the escalation process.
- Provide as much detail as possible in each section. The more information you provide, the faster and more accurately we can address your concern. You can submit the form anonymously if you choose, however, by doing this you will not receive any updates or resolutions on the issue.
- HCPF utilizes Authorization Forms which allow us to release a member's health information to a third party. By selecting your relation to the member, it has been identified that you will require one of these forms. In order to receive updates on this case, you will need to upload a HCPF Third Party Release form, Personal Representative form, or a Non-Attorney Authorization Form if one is not already on file for you. View HIPAA Forms Page.
- Slide the Toggle button to "Active" to be able to upload forms and other files. The upload section appears on the next screen.
- Slide the Toggle button to "Active" to be able to upload forms and other files. The upload section appears on the next screen.
- HCPF utilizes Authorization Forms which allow us to release a member's health information to a third party. By selecting your relation to the member, it has been identified that you will require one of these forms. In order to receive updates on this case, you will need to upload a HCPF Third Party Release form, Personal Representative form, or a Non-Attorney Authorization Form if one is not already on file for you. View HIPAA Forms Page.
- Select the Appropriate Ticket Type for Transition Support
- Transition Complaints - select this ticket type for issues related to member complaints/grievances about any aspect of the transition process. These complaints can be about unsatisfactory experiences, issues with transition staff, etc. For example:
- Complaints about Group In-Reach or At-Risk outreach
- The need for a Transition Coordinator change
- Transition Coordination payment issues
- Transition Escalation - select this ticket type for general concerns or issues related to a member’s transition, or specific incidents with transitioning back into the community. For example:
- Delays in services outside of expected wait times
- Eligibility delays
- Lack of available providers in the area
- Challenges obtaining equipment for members
- Resistance from nursing facility staff to support transitions
- Transition Housing/At-Risk Diversion Services - select this ticket type if your escalation pertains to housing services, vouchers, or environmental adaptations (home modifications prior to discharge).
- Transition Complaints - select this ticket type for issues related to member complaints/grievances about any aspect of the transition process. These complaints can be about unsatisfactory experiences, issues with transition staff, etc. For example:
- Provide as much detail as possible in each section. The more information you provide, the faster and more accurately we can address your concern. You can submit the form anonymously if you choose, however, by doing this you will not receive any updates or resolutions on the issue.
- Submit the Webform
- Click Select Next once you have completed all sections.
- If needed - upload any related HIPAA forms or other documentation.
- Click Submit on the following page to finalize your submission.
- Confirmation Email - After submitting the form, you will see a confirmation screen with a ticket number. Please keep this ticket number as reference. If you have any questions about this submission, you may be asked for that ticket number. If you provided a contact email when submitting the form, you will also receive a confirmation email acknowledging your ticket submission and ticket number.
Priority Levels and Resolution Timelines
- Urgent: Initial Response within 4 hours of ticket assignment, Resolution within 2 business days.
- High: Initial Response within 1 business day of ticket assignment, Resolution within 4 business days.
- Medium: Initial Resolution within 2 business days of ticket assignment, Resolution within 7 business days.
- Low: Initial Response within 4 business days of ticket assignment, Resolution within 14 business days.
Receiving a Response
When completing the escalation form, please ensure you provide the most accurate and up-to-date contact information for any follow-up regarding your concern. If this information is included, an Escalation Team Member will reach out based on the above listed timelines within a confirmation of ticket submission, followed by any updates and/or resolutions that can be shared, based on the priority status of your ticket.
If you choose not to include an email or phone number HCPF will not be able to provide you any updates to your submitted grievance.
Rapid Reintegration and Rapid Referral
- Updated Launch Date - January 2026
- Changes to Care and 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 prior to a member transitioning into the community to decrease rates of reinstitutionalization due to health and safety concerns.
- Fall of 2024 - HCPF collaborated with Case Management Agencies during meetings and workgroups to discuss processes and changes.
- Q&A (coming soon)
- Additional information will be provided at a later date, when available.
Contact Us
In-Reach Team Project Feedback form - provide feedback, ask questions, and report issues and/or concerns outside of traditional meetings.
Email: hcpf_clo_inreach@state.co.us
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