Cmp Funded Nursing Facility Transition Services

Cmp Funded Nursing Facility Transition Services

NURSING FACILITY TRANSITION NOTICE & EXCEPTION REQUEST FIELD DEFINITIONS

A completed Nursing Facility Transition (NFT) Notice and Exception Request must be submitted to MDCH as soon as a nursing facility resident decides to work with a waiver agent or CIL transition agent on a transition to the community. Exceptions for participants who:

  • have been in the nursing facility for less than four months (and the waiver agent does not have a corresponding NFT participant who has been in the facility over six months),
  • have been in the nursing facility for greater than four months but less than six months (and the waiver agent does not have a corresponding NFT participant who has been in the facility over six months),
  • have one-time transition costs that are expected to exceed $3,000.00,
  • are not in a facility, but are at imminent risk of facility placement (diversion),
  • LTCC (Long Term Care Connection) unable to complete transition interview, Waiver Agent or Center for Independent Living wishes to do so (attach LTCC approval for request)
  • Transitionee needs coordination/support services beyond 6 months post transition
  • Other – need to include explanation

The following is an explanation of all fields in the "Nursing Facility Transition Notice and Exception Request Form." The transition agent must complete all fields for each NFT notice and exception request (if needed) submitted.

When completed fax form to (517)241-7816

NFT Notice & Exception Request Field / DESCRIPTION
Transition Agent Information:
Agency / The name of the agency facilitating the NFT.
Today’s Date / The date the Transition Exception Notice was completed.
Contact’s Name / The name of the person MDCH should contact for this transition.
Contact’s Phone / The phone number of the person MDCH should contact for this transition.
Contact’s Email / The email address of the person MDCH should contact for this transition.
Transitionee Information:
Last Name / The last name of the NFT participant.
First Name / The first name of the NFT participant.
Date of Birth / The NFT participant’s date of birth.
Medicaid I.D. # / The NFT participant's ten-digit Medicaid Recipient ID number. If pending enter in participants Case number.
Social Security # / The NFT participant’s Social Security Number.
Date of Initial NFT interview / The date the waiver agent initially interviewed NFT participant in the nursing facility
NF Name / Name of Nursing Facility participant is currently admitted to.
City & State / City and State of where Nursing Facility is located.
Admission Date / The date the individual was admitted to the nursing facility.
Date of Hospitalization / If NFT participant was in the hospital prior to NF placement , provide dates
Transferred From / If the case was referred to you by another agency, the name of the agency
Exception Needed / Complete this section if an exception request is needed
Type of Exception / Check the box most appropriate to the type of exception requested for this NFT participant.
Comments / Use this space to provide your rationale for requesting an exception. Include information about the individual’s condition and support system, barriers to transitioning, and services the individual will need post-transition.
Transition Agent Information (REQUIRED)
Agency (Name & city): / Today’s Date:
Contact’s Name:
Contact’s Phone: / Contact’s Email:
Transitionee Information (REQUIRED)
Last Name: / First Name:
Date of Birth: ___/____/____ / Medicaid I.D. #: (If pending, Case #)
Social Security #: ___- ___-___ / Date of Initial NFT interview: ____/____/_____
Nursing Facility Name: / City & State:
Date of admission to nursing facility: (Nursing Facility Admission Sheet Required) ____/____/_____
If hospitalized or in another NF immediately prior to nursing facility placement, date of immediately preceding institutionalization: ___/___/____
If transferred to your agency from another, which agency made the referral?
Phone number where transitionee can be reached: ___-___-____ / Does transitionee need interpreter or translation services? If yes, describe.
Type of Exception Requested (IF NEEDED) and Rationale for Request
Less than 6 months in nursing facility prior to transition Transitionee needs coordination/support services beyond6 months post-transition
One-time transition costs, excluding coordination and support, exceed $3,000
Move up on wait list Other (describe
Diversion of AFC/HFA resident with impending nursing facility admission)
Diversion of individual in the community with impending nursing facility admission
Your request must include a rationale. For exception requests to work with individuals who have been in a nursing facility for less than 4 or 6 months, or to move them up on the wait list, include: 1) individual’s condition and support system, 2) transition barriers you will address, and 3) services needed post transition. For requests to spend in excess of $3000, describe all expenditures you wish to make. For a diversion request attach a completed “Imminent Risk of Nursing Facility Placement Assessment”, barriers the person has to staying in their current situation and services needed. (Add additional pages if needed)

Nursing Facility Transition Notice &Exception Request

DCH-1443 (Revised 7/09) Previous editions are obsolete

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