6300, Developing and Revising the Transition Plan

Revision 23-1; Effective Dec. 20, 2023

In conjunction with the SPT, the ECC coordinator develops and revises, as needed, a person’s Form 1053, Transition Plan. The ECC coordinator must develop Form 1053, or revise it as needed, and send it to the SPT members within 10 calendar days after the SPT meeting.

6310 Transition Plan

Revision 23-1; Effective Dec. 20, 2023

Information documented on Form 1053, Transition Plan.

Section 1, Individual Information — Name of the person, CARE ID, Medicaid number and date.

Section 2, Community Program Choice — This section identifies the community program selected by the person or LAR, the name of the responsible party for requesting a slot and the projected date of request.

Section 3, Service Coordination Plan — This section describes the service coordination plan, including duration and frequency of in-person meetings between the person and the ECC coordinator, which are pre-printed on the form. The duration of service coordination is throughout the transition process, and the frequency of in-person visits is at least monthly. This section also lists all the activities to be coordinated and monitored by the ECC coordinator during the transition process.

Section 4, Identified Supports — This section describes all supports the person needs to live in the community, whether they are essential or non-essential, whether the selected living option provides the support, the due-date for the provision of non-essential support, and the name of the responsible party for ensuring the support is provided.

Section 5, Plan for Choosing a Program Provider — This section has a summary of the person's or LAR’s plan for choosing a program provider, such as conducting interviews and trial visits with potential program providers, the name of the responsible party for implementing the plan, and the projected date of completion.

Section 6, Barriers to Transitioning to a Program — The barriers listed in this section originate in Section 8 of Form 1054, Community Living Options, and additional barriers may be identified by the SPT. As transition planning progresses, some of the barriers may change and some will be resolved. This section also describes the SPT’s possible solutions to the barriers, how the SPT can implement the solutions, and any needed follow-up activities.

Section 7, Transitioning from the Nursing Facility — This section identifies the selected program provider and the projected move date. It also includes the pre-move preparations that must be arranged before the day of transition and the name of the responsible party for ensuring the arrangement is made.

Section 8, Post-Move Monitoring Dates — This section auto-populates the period in which post-move monitoring visits must be conducted by an ECC coordinator.

Section 9, Community Living Data — This section is for listing all community living information, including names, contacts, addresses and phone numbers. It serves as a quick reference for important information related to serving a person. This information must be included as it becomes known.

Section 10, Agreements — This section describes the agreements between the LIDDA and the community program provider.

Section 11, Service Coordinator Signature — This section is for the ECC coordinator to affirm that the Transition Plan was developed based on SPT decisions and includes the ECC coordinator’s printed name, signature and date.

6320 Barriers Preventing a Transition to the Community

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator must:

  • ensure that if barriers preventing a transition to the community are identified in Section 8 of Form 1054, Community Living Options, they are included in Section 6 of Form 1053, Transition Plan, in addition to any barriers the SPT may identify;
  • ensure the SPT discusses the barriers, possible solutions to the barriers, and how the SPT can implement the solutions and any needed follow-up activities; and
  • document the resolutions and actions for implementation in Section 6 of Form 1053.

6330 Documents in an Person's Transition Packet

Revision 23-1; Effective Dec. 20, 2023

A complete transition packet for a person has:

6340 Individual Profile

Revision 23-1; Effective Dec. 20, 2023

Form 1063, Individual Profile – Nursing Facility, is addressed in Section 5460.1, Individual Profile, and is developed and revised by the habilitation coordinator.

Note: If revisions to the person’s Form 1063 are necessary based on discussions during an SPT meeting convened by the ECC coordinator, then the habilitation coordinator is responsible for making the necessary revisions and sharing the revised Form 1063 with the ECC coordinator and the other SPT members.

6350 Sharing the Transition Plan, Individual Profile, and Transition Packet

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator is responsible for providing a copy of the person’s Form 1053, Transition Plan, to all SPT members within 10 calendar days after the SPT meeting during which it was developed or revised.

The ECC coordinator must also share a person’s transition packet with an SPT member upon request.

6360 SPT Member Believes Transition Plan Does Not Accurately Reflect SPT Decisions

Revision 23-1; Effective Dec. 20, 2023

If an SPT member believes Form 1053, Transition Plan, does not accurately reflect SPT decisions, then:

  • if the ECC coordinator agrees with the SPT member, the ECC coordinator corrects Form 1053 to accurately reflect the SPT decision; or
  • if the ECC coordinator does not agree with the SPT member, the ECC coordinator presents the issue to the SPT to resolve the discrepancy.