22-1054m Nursing Facility Transition/Diversion Program Promotes Independent Living
Date: 12/12/22
Services help individuals live in the community and avoid institutionalization
Nursing Facility Transition/Diversion services facilitate members' transition from nursing facilities to home-like settings. They avoid skilled nursing admissions for members with an imminent need of nursing facility level of care (LOC).
The services are for individuals transitioning from a licensed health care facility to a living arrangement in a Residential Care Facility for the Elderly (RCFE) or an Adult Residential Facility (ARF).
Eligibility
To qualify for Nursing Facility Transition/Diversion services, members must meet the following criteria.
For Nursing Facility Transition:
- Has resided in a nursing facility for at least 60 days.
- Willing to live in an assisted living setting as an alternative to a nursing facility.
- Can reside safely in an assisted living facility with appropriate and cost-effective supports and services.
For Nursing Facility Diversion:
- Interested in remaining in the community.
- Can reside safely in an assisted living facility with appropriate and cost-effective supports and services.
- Meets the minimum criteria for receiving medically necessary nursing facility LOC and chooses to receive it in an assisted living facility rather than a nursing facility.
Nursing Facility Transition/Diversion services
- Wraparound services provided in a home-like environment such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), companion services, medication oversight, and therapeutic social and recreational programming.
- 24-hour direct care staff on-site to provide supervision, safety, and security and to meet unpredictable needs in a way that promotes maximum dignity and independence.
- Allowable expenses -- defined as expenses necessary to enable a person to establish a community facility residence, excluding room and board. Allowable expenses include:
- Assessment of the member’s housing needs and presenting options.1
- Assessment of the service needs of the member to determine whether the member needs enhanced on-site services at the RCFE/ARF.
- Assistance in securing a facility residence, including the completion of facility applications, and securing required documentation (e.g., Social Security card, birth certificate, prior rental history).
- Communication with facility administration and coordination of the move.
- Establishment of procedures and contacts to retain facility housing.
- Coordination ensuring that members needing enhanced services to be safely and stably housed in RCFE/ARF settings have Community Supports and/or enhanced care management services.
Billing service codes
Billing for Nursing Facility Transition/Diversion services must use service code: T2038 with modifier U4.
Allowable Community Supports providers
Providers must have experience and expertise providing housing-related services and supports in a culturally and linguistically appropriate manner. Providers must use best practices in rendering services. Examples of providers include case management agencies, home health agencies, Medi-Cal managed care plans, and ARF/RCFE operators.
State services to avoid
Examples include skilled nursing facility services, inpatient hospital services, and psychiatric inpatient stays.
Authorization guides
For more information on Community Supports (CS) authorization guides and eligibility criteria, access the provider website > Forms & Tools under Community Supports (CS) Authorization Guides.
1Refer to the Housing Transition Navigation Community Supports authorization guide for additional details.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.