Complex Transitions Team

The Complex Transitions Team supports people who might benefit from DHS technical assistance to move from hospital and institutional settings back into the community. The team connects with subject matter experts across departments and divisions within the state to be a single point of contact for people who need to navigate the supports available through DHS.

The Complex Transitions Team technical assistance is not a substitute or waiver of requirements, nor a substitute for regular communication channels and processes. The hospital must continue to collaborate with the lead agency and the support team working with the person. If you have an exceptional circumstance that may require DHS consultation, please contact us through the referral form under the How to get help tab below.

How to get help
Resources
Contact us

How to get help

Before submitting a Complex Transitions Referral Form, the hospital must reach out to the lead agency that serves the person. Lead agencies are the first point of contact for human services supports. You can find a list of lead agencies here: County and tribal nation offices.

If the person you are helping needs a MnCHOICES or other county service assessment, call your county or tribal nation to request an assessment. Use the Minnesota tribal and county directory to find the right phone number.

If the person is going through or is under the commitment process, the Rule 20 process, the forensic process, or is in your facility because of a legal order, you must reach out to Central Pre-Admissions for assistance. The Central Pre-Admission office is staffed around the clock. Reach them at:
- Toll free: 1-866-966-2337
- Twin Cities metro area: 651-431-5337.
If the person is under 18, you can reach out to Central Pre-Admissions for assistance at any time.

Referral Form

Alert: As of April 18, 2024, the Complex Transition Referral form is temporarily down. Please send encrypted referrals in the interim to DHS.ComplexTransition@state.mn.us. We will update this page when the form is again working.

If you have reached out to the lead agency and the person has been unable to discharge for a week because they need complex supports, you may submit a referral to the Complex Transitions Team through the Complex transitions referral form (PDF).
Resources

Acute Care Transitions Advisory Council

DHS formed the advisory council in October 2023 to create supports for children and adults who face barriers when moving from hospitals and other settings into their home and community.

Advocacy resources

Disability Law Center: The Minnesota Disability Law Center (MDLC) addresses the legal needs of people with disabilities. A statewide project, MDLC provides free civil legal assistance to people with disabilities on legal issues that are related to their disabilities.

Ombudspersons resources
Finding supports and services
- Disability Hub MN: Disability Hub MN is a free statewide resource network that helps you solve problems, navigate the system and plan for your future. The Hub can help you create your best life, your way. Visit About the Hub to learn more.
- Disability Benefits 101
- Housing Benefits 101
- Senior Linkage Line: The Senior Linkage Line works with providers and lead agencies across the state to support older Minnesotans. They help by connecting your clients to local resources, assisting with smooth transitions between facilities/residences, providing Medicare information to your staff and clients, and much more. The Senior LinkAge Line also works with providers and other partners to:
  - Receive referrals from hospitals, nursing facilities, clinics, assisted living facilities, hospice and home care to follow up with people who need help to return or remain safely in their homes.
  - Refer people to providers to help connect them to services.
  - Work with county, managed care and tribal nations to make referrals when a person could benefit from lead agency programs and assistance.
  - Partner with providers and lead agencies to streamline federal and state requirements like preadmission screening and verification codes for moves to nursing and assisted living facilities
- Moving Home Minnesota: Moving Home Minnesota helps people on Medical Assistance (MA) move out of institutions. It helps pay for services that your MA or MA-Waiver benefits will not pay for, provides counseling and makes sure that transitions to the community go smoothly.
- Relocation Service Coordination: Relocation service coordination is a type of case management to help people who want to move out of certain institutions into the community. RSC helps people plan and arrange for the services and supports they need to live in the community.
- Housing Stabilization Services: Housing Stabilization Services is a new Minnesota Medical Assistance benefit to help seniors and people with disabilities, including mental illness and substance use disorder, find and keep housing.
Finding providers
- MinnesotaHelp.info: Visit MinnesotaHelp.info for more home and community-based services and waiver providers.
- Minnesota Current Openings Live
- Fast Tracker: FastTrackerMN.org is a dynamic behavioral health search tool that gives Minnesotans access to real time information and availability. It improves connections for people and collaboration for systems.
- FindTreatment.gov: FindTreatment.gov is a confidential and anonymous resource for people seeking treatment for mental and substance use disorders in the United States and its territories.
- Minnesota Health Care Programs (MHCP) Provider Directory: This directory may not have all home and community-based providers listed.
- Psychiatric Residential Treatment Facilities.
- Children's Residential Facilities:
- Family First Prevention Services-certified programs:
Contact us
If you have questions, email us at DHS.ComplexTransition@state.mn.us.