Transitional Case Management
Ensuring that individuals with developmental disabilities live in the setting of their choice with the services they need is a priority for most public health and human service agencies, but many lack the resources to provide the coordinated care needed to accomplish this goal. The University of Massachusetts Medical School’s Commonwealth Medicine division developed the Transitional Case Management (Trans CM) program in partnership with state agencies to transition certain individuals with developmental disabilities from nursing facilities into community living settings. This administrative activity coordinates services that address efforts to remove barriers to community living for nursing home residents.
Trans CM’s goal is to move individuals into state-funded community living environments or a family home with additional state funded supports, where theses individuals will receive our support for up to one year after nursing facility discharge. Trans CM staff assists them in accessing housing, financial support, medical services, equipment, home modifications, and personal care workers – creating a model for service delivery that streamlines access to the critical services necessary to successfully transition to community living.
Our highly skilled, hands-on case managers have expertise in working with people with developmental disabilities and providing clinical social work, rehabilitation and mental health services. This expertise, coupled with our onsite nursing, physical, occupational, and respiratory therapy consultation, enables us to successfully transition individuals into the community. We draw on these multi-disciplinary skills as well as the clinical resources of the Medical School to develop creative, personalized service plans for each individual in the program.
Using a person-centered approach, the Trans CM team of health professionals closely coordinates with the individuals, their guardians and families, the state, nursing facilities, providers, and residential agencies to identify the living situation and day supports that best match the individuals’ needs, interests, and choices. This matching process provides the individual with the best chance for a satisfying and successful community placement. An integral part of this process is the identification and implementation of an individualized system of supports coordinated by the Trans CM team in conjunction with the Massachusetts Office of Medicaid. Trans CM can assess the need for, provide prior authorization for, and coordinate necessary Medicaid covered services such as home health aides, durable medical equipment, outpatient services, nursing services, personal care assistance (PCA), and respiratory therapy.
Trans CM works with other Commonwealth Medicine programs to assist Massachusetts in rebalancing the provision of long term care with a greater focus on community placement. Through collaborative opportunities, Trans CM evaluates the methods to transition individuals with complex medical and behavioral issues out of institutional settings.