Section 240. Community Transition Services

A. Service description.

Community transition services are provided to individuals who are leaving the PRTF and have chosen to receive services in the community. Community transition services include assessment of the child and family; assistance with meeting the requirements of waiver enrollment; referral for Medicaid eligibility; developing a community plan of care in coordination with the family, CSA (if involved), and other involved parties; identifying community service providers; and monitoring the initial transition to the community. Community transition services do not include monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes.

Community transition services ensure the development, coordination, implementation, monitoring, and modification of comprehensive service plans; link recipients with appropriate community resources and supports; coordinate service providers; and monitor quality of care.

Community transition services may be provided in the PRTF, in the home, school or other community locations.

Community transition services may be provided up to three months prior to discharge from the PRTF and one month after discharge. The cost of community transition services is considered to be incurred and billable when the client leaves the PRTF and enters the Children's Mental Health Waiver.

B. Criteria. In order to qualify for these services, the client must be a resident of the PRTF and also have been identified as a possible participant in the Children's Mental Health Waiver.

C. Service units and service limitations. The unit of service shall be 15 minutes with a maximum of 80 units for each admission to the Children's Mental Health Waiver.

Services provided must be documented in records maintained by the community transition services provider. Documentation may be required to be submitted to DMAS.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, professionals rendering community transition services must be DMAS-enrolled providers of treatment foster care case management, DMAS-enrolled providers of mental health case management services or be local CSA coordinators or FAPT members who meet the knowledge, skills, and abilities established for mental health case managers.

E. The following documentation is required:

1. A comprehensive services plan that contains at a minimum, the following elements:

a. Identifying information: client's name and Medicaid number; provider name and provider number; responsible person and telephone number; effective dates for supporting documentation; and semi-annual review dates, if applicable;

b. Identified services, provider names and individual service plans;

c. Targeted objectives, time frames, and expected outcomes.

2. Ongoing documentation of all contacts. All notes must include:

a. Specific details of the activities conducted;

b. Dates, locations, and times of service delivery;

c. CSP objectives addressed;

d. Services delivered as planned or modified;

e. Effectiveness of the strategies and client's and family/caregiver's satisfaction with service;

f. Client status; and

g. Outcomes and effectiveness of the comprehensive services plan.

F. When transition coordination services are completed, a final CSP must be discussed and forwarded to the ongoing case manager before the end of transition coordination. The transition services coordination provider must include:

1. Strategies utilized;

2. Objectives met;

3. Unresolved issues; and

4. Consultant recommendations.

Historical Notes

Derived from Volume 24, Issue 02, eff. December 1, 2007.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.