Transition to Community Initiative

The Transition to Community Initiative is a grant program initially established in 2013 to support people who encountered barriers in trying to move from institutions and returning back into the community setting of their choice. The grant may serve people who are not eligible for Medical Assistance (MA), or whose needs are not fully met by current MA-covered services, to support their moves to settings in the community.

The Transition to Community Initiative is designed to:

Help people live as independently as possible in the least restrictive setting.
Provide access to personalized services that meet both short- and long-term developmental or treatment needs.
Help people to build and maintain relationships with natural supports, such as family members, friends, neighbors, coworkers and other community connections.
Reduce barriers that make it easier to participate fully in the community.

All grantees must ensure services are delivered using a person-centered planning process and informed choice decision-making. To learn more about person-centered practices and informed choice, visit the Person-centered practices webpage.

Background
Services
WIT program
Eligibility
Evaluation
Administration

Background

The Legislature established the Transition to Community Initiative in 2013 to reduce the time people remained in the Anoka Metro Regional Center and the Forensic Mental Health Program when services were no longer clinically necessary.

The initiative also aligns with Minnesota’s Olmstead Plan to support people as they receive services in the most integrated setting appropriate to the person. The initiative is also designed to assist people who are not eligible for MA, or who need additional supports and services not covered by MA, to support them to live in the least restrictive setting possible.

Since the program began, statutory authority has expanded to define and clarify purpose, eligibility, use of grant funds and outcomes. (See Minn. Stat. § 256.478 for more information).

Visit the Minnesota Olmstead Plan page to find more information about the history, goals and reports related to the plan.
Services

Technical assistance

A DHS coordinator with extensive clinical and community experience in supporting people with complex needs may assist the discharge planning team to find unique solutions and work through administrative or logistical delays.

Grants to counties

The Bed Hold grant option is a temporary strategy for people who are committed to the Forensic Mental Health Program and need to petition the Special Review Board to be discharged to a residential service provider in the community.
- The person’s request for provisional discharge begins with the treatment team and county of responsibility’s support before sending a request to the Forensic Review Panel to review.
- To request the Special Review Board hearing, the person must have a provisional discharge plan that identifies the residential service provider and the site/location where they will be living.
- Once the provisional discharge plan is completed, it might take several months to schedule the SRB hearing and get final approval from the DHS commissioner. The residential service provider must be willing to hold the bed for this person. Until the person is provisionally discharged, the provider is unable to bill for waiver services, resulting in lost revenue for the provider. The initiative has made funds available as an incentive for licensed residential providers to hold a vacancy open for someone who must wait for final approval from the SRB and DHS commissioner to be approved for discharge from the Forensic Mental Health Program.
- The program contracts with lead agencies to pay the provider after the person is discharged to their new home.
Service capacity

Capacity to provide services under this initiative is dependent on available funding. As a result, not everyone who is eligible will receive funding for services for which they apply.
WIT program

The Whatever It Takes (WIT) program supports person-centered transitions for people leaving state and community-based hospitals.

The Transition to Community Initiative funds three community-based grantees through a competitive RFP process to provide WIT services. These grantees offer specialized, targeted supports for people who face complex discharge barriers, including mental health symptoms, recidivism and criminal histories. WIT staff work intensively with each person to create a person-centered transition plan, secure needed resources and promote long-term stability in community settings.

How the WIT program works
1. DHS TTCI staff reviews WIT referrals to determine eligibility.
2. On approval, DHS connects the person with a WIT provider able to deliver the necessary services.
3. WIT providers collaborate with the person, their natural supports, case managers, hospital staff and other community partners to develop and implement a person-centered plan focused on community living success.
Program mission and goals

Established in 2014 through the Transition to Community Initiative, the WIT program aims to:
- Support people to live as independently as possible in the least restrictive setting.
- Deliver specialized, targeted services for people discharging from Anoka Metro Regional Center, the Forensic Mental Health Program, community behavioral health hospitals and community hospitals.
- Promote a smooth, long-lasting move into the community.
- Provide flexible funding to address individual needs, reduce discharge barriers, lower recidivism and increase stability.
- Expand and enhance community resources that support successful transitions.
- Use person-centered planning to align supports with each person’s preferences and needs for community placement.
Overall, the WIT program ensures that people with high and complex needs receive the intensive, person-centered support required to maintain stability and thrive in their community homes.
Eligibility

In 2023, the Legislature expanded eligibility criteria to include more settings a person may discharge from into the community. Existing WIT grant contracts do not include this broader eligibility that applies to people younger than 18.

To qualify for support through the initiative, a person must:
- Show how current services fail to meet their treatment and service needs and how those needs can be met in the community with additional support.
- Meet one of the following criteria:
  1. The criteria under Minn. Stat. §256B.092, subd. 13, or Minn. Stat. §256B.49, subd. 24.
    - If additional waiver allocations and necessary resources assure timely discharges from Anoka-Metro Regional Treatment Center and the Forensic Mental Health program, formerly referred to as the Minnesota Security Hospital in St. Peter, and meets all the following criteria:
      - Qualify for the Brain Injury, Community Access for Disability Inclusion, or Community Alternative Care waivers.
      - Would otherwise remain in the hospital.
      - Face delayed discharge without the available waiver.
      - Have met treatment goals and no longer need hospital-level care.
    - These additional waivers must be cost-effective under the federally approved plan. Any corporate foster care homes created for this purpose are exempt from normal limits under Minn. Stat. 245A.03, subd. 7(a).
  2. Is ready for discharge from an eligible setting because they have met treatment objectives and no longer require a hospital-level care, residential-level care or a secure treatment setting. Discharge would be substantially delayed without additional community resources available through the initiative.
  3. Currently receiving 24-hour customized living or community residential services (under Minn. Stat. 256B.4914), and:
    - Expresses a desire to move.
    - Has received approval from the commissioner.
  4. Has needs beyond current programs and service models that can only be met through Transition to Community Initiative grant-funded supports, thereby allowing access to appropriate treatment in the least-restrictive environment.
For more information, see Minn. Stat. §256.478 subd. 2.
Evaluation

DHS evaluates the Transition to Community Initiative based on its impact in the following areas:
- Improving discharge timelines for people who no longer require hospital-level care.
- Securing and maintaining housing, including returns to family or community homes.
- Preventing unnecessary admissions to high-level care facilities, such as Anoka Metro Regional Treatment Center and the Forensic Mental Health Program.
- Reducing recidivism, or repeat admissions, to state institutions.
- Supporting people to live successfully in the least-restrictive, community-based setting.
The initiative helps identify gaps in existing care systems and transitional supports to ensure a more person-centered discharge planning.
Administration

The Minnesota Department of Human Services Transitions, Tribal and Transformations Division oversees the Transition to Community Initiative. Grant applications, program monitoring and outcome evaluation are administered through DHS in partnership with the state Department of Direct Care and Treatment, lead agencies, community-based providers and other interested parties. Lead agencies and staff at institutional settings may contact the Transitions, Tribal and Transformations Division with questions about or help with the initiative.