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Instructions
Updated: 1/2025
Purpose
Local intellectual and developmental disability authorities (LIDDAs) use Form 1053 to describe the activities to transition the person from the nursing facility (NF) or medium or large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) to the community.
When to Prepare
The Enhanced Community Coordination (ECC) coordinator completes the form when a person who lives in a nursing facility or ICF/IID chooses to transition to a specific community program. It is revised, as necessary. This form is not used for people transitioning from a state supported living center (SSLC).
Detailed Instructions
Section 1: Person’s Information
Person’s Name — Enter the name of the person who is transitioning to the community.
CARE ID — Enter the person’s Client Assignment and Registration (CARE) System identification number.
Medicaid No. — Enter the person’s nine-digit Medicaid number.
Date — Enter the date the form is developed or revised.
Section 2: Community Program Choice
Community-based program to be pursued — Enter the name of the community program the person or their legally authorized representative (LAR) selected.
Date Program Was Offered — Enter the date the person was offered the identified program.
Section 3: Enhanced Community Coordination Plan
List all activities the ECC coordinator will coordinate and monitor during the transition process — Enter the planned activities the ECC coordinator will coordinate and monitor. Include activities to help the person obtain their desired outcomes. Add rows as needed.
Section 4: Identified Supports
For nursing facility transitions, refer to the person’s most recent Form 1054, Community Living Options (CLO) when first completing this section. For ICF/IID transitions, this information will be gathered during the discovery process.
Description of Support/Comments —Provide details about each support the person requires to transition to and live in the community. If a listed support is unnecessary, enter NA.
Essential Support — Check the box if the support has been identified as essential and needs to be in place the day the person moves into the community.
Does selected program provide this support? — Check Yes or No based on the selected program’s availability to provide the identified supports.
Due Date —For supports identified as Essential Supports, enter the projected move date identified in Section 7. For supports not identified as Essential Supports, identify the date the non-essential support needs to be in place.
Name of Person responsible for arranging support — Enter the first and last name of the person who will make sure the identified support is provided.
Add Row for Other — If multiple supports are to be included in a field, such as a person has three pieces of durable medical equipment, enter each support separately in the Other fields. Add rows to include supports not already listed in this section.
Section 5: Plan for Choosing a Program Provider
Summarize the plan for interviews or trial visits with potential providers — Describe the plan for arranging interviews or trial visits with potential providers.
Responsible Party — Enter the first and last name of the person responsible for arranging interviews or trial visits.
Projected Date of Completion — Enter the projected date arrangements for interviews or trial visits will be completed.
Insert additional rows — Click to add activities with potential providers.
Section 6: Barriers to Transitioning to a Program
Barriers from the CLO — Select from the drop down menu the barriers that prevent the person from transitioning from the nursing facility into the community. These barriers originate from the Community Living Options form, Section 8. For ICF/IID transitions, enter NA.
SPT Proposed Solution/Follow-up Activities — Describe the SPT’s proposed solutions to each barrier and the follow-up activities to implement the solutions.
Insert additional rows for CLO Barriers — Click to add if the person has additional CLO barriers.
Barriers identified by the SPT— Enter barriers identified by the SPT that prevent the person from transitioning into the community. Complete this section for both NF and ICF/IID transitions.
SPT Proposed Solution, Follow-up Activities — Describe the SPT’s proposed solutions to each barrier and the follow-up activities to implement the solutions.
Insert additional rows for SPT Barriers — Click to add if the person has more SPT barriers.
Section 7: Transitioning from the Nursing Facility or ICF/IID
The person or LAR has selected — Enter the name of the community program provider the person or LAR selected in the space provided.
The essential supports and the following pre-move preparations must be in place before the projected move date of — Enter the date the SPT has agreed to as a projected date the person will move into the community. This date may change because of unforeseen circumstances and may be updated if necessary. All essential supports identified in this transition plan must be in place before the projected move date.
The SPT agrees the following pre-move preparations must be arranged before the day of transition — Complete the list of items that must be arranged before the day of transition. Add specific numeric amounts for the trust fund account, as well as amounts for the daily supply of medication, nutritional and dietary products, and medical supplies. List any adaptive, assistive or protective equipment that will accompany the person in the Other field. Describe anything else that must be arranged in the Other field. Add or remove rows as needed. Enter NA if the item is not applicable. Enter the first and last name of the person responsible for arranging for each item listed.
Section 8: Post-Move Monitoring Dates
Time Frame for Monitoring Visit to be Completed — Dates will auto-populate based on the projected move date from Section 7.
Section 9: Community Living Data
List all community living contact information in this section. Include names, addresses and phone numbers. It is a quick reference for important information about serving a person in the community. Enter the information as it becomes known.
Section 10: Agreements
This section describes agreements for certain SPT members.
Section 11: Signatures
ECC Coordinator Name — Enter the printed name of the ECC coordinator who developed the plan.
ECC Coordinator Signature — The ECC coordinator who developed the plan signs the form.
Date —Enter the date the ECC coordinator signs the form.
Provider Representative Name — Enter the printed name of the provider representative who helped develop the plan.
Provider Representative Signature — The provider representative who helped develop the plan signs the form.
Date — Enter the date the provider representative signs the form.
Person or LAR Name — Enter the printed name of the person or LAR.
Person or LAR Signature — The person or their LAR signs the form.
Date — Enter the date the person or LAR signs the form.