Complex transitions is a unit within the Transitions, Tribal and Transformation Division under the Aging and Disability Services Administration at DHS. The complex transitions team supports lead agencies – counties, tribal nations and managed care organizations – working with people who live in hospitals or institutions, but no longer need institutional care as they transition back into the community. CT helps lead agencies to address the barriers that might be encountered in planning a transition back to a person's community. The complex transitions team helps lead agencies to address the barriers that might be encountered in planning a transition back to a person’s community.
The complex transitions team provides technical assistance and connections with subject matter experts across state agencies to help with the person's transition to their community.
No. The complex transitions team is not a substitute or replacement of case management services. Nor is it a substitute for regular communication channels and processes. Continued collaboration between the hospital or institution and the lead agency is a requirement of complex transitions involvement. Developing a plan with the person for their transition to their community is still an expectation.
Referrals to the complex transitions team may be made by any hospital, institution or lead agency in Minnesota by completing the Complex Transitions Referral Form (PDF).
Yes. The lead agency must remain involved through the entire process. A complex transitions coordinator will collaborate with and provide support to the lead agency, as requested, to assist in breaking down the barriers and bridging the gaps in services that are preventing the person from transitioning to their community.
The complex transitions team stays involved for up to six months or more after the hospital or institution discharge occurs.
While transitions are well planned to make sure there is support for any challenge that might arise, not all challenges can be predicted or anticipated. The complex transitions team will check in with the lead agency or community support location regularly to make sure the person has what they need to remain in their community. The complex transitions team also welcomes contact from the lead agency or community support location if there are questions or issues that need to be planned around to prevent unnecessary returns to a hospital or institution.
To consider a referral appropriate for complex transitions, the complex transitions team will confirm that situations meet the following eligibility criteria:
The person must be eligible for a Minnesota Health Care Plan (MHCP). This means that they are either in receipt of MHCP, in the application process for MHCP or are determined to be eligible for MHCP.
The person must have been in the hospital or institution for more than seven days.
The person’s treatment goals must be complete and they no longer meet the established level of care provided by the hospital or institution.
The lead agency has been actively involved and has exhausted all options in seeking community placement or planning for the person’s return to their community.
No. The complex transitions team is not a placement authority. We do not develop placement options and assist with creating services. The team does not have the authority to require a service provider to provide services for a person.
Yes. DHS has several other transition teams focusing on supporting the person’s transition to their community following hospitalization or institutionalization. However, the complex transitions team does not duplicate the services these teams provide. The complex transitions team is only involved if the person’s transition back to their community is complex and involves barriers that cannot be resolved with the existing community support available. The complex transitions team provides additional support and resources that can help to resolve the overarching barriers and obstacles to the person’s transition to their community.
