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 are no longer in need of 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 the 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 community.
The complex transitions team assistance is not a substitute or waiver of requirements, nor a substitute for regular communication channels and processes. Continued collaboration between the hospital/institution and the lead agency to develop a plan for transition to community is still an expectation.
The hospital social worker completes the Complex Transitions Referral Form (PDF) online so the complex transitions team can become connected with the lead agency.
As of July 1, 2024, referrals to the complex transitions team may be made by any hospital in Minnesota by completing the Complex Transitions Referral Form (PDF).
The lead agency will be contacted by someone from the complex transitions team to assist with any technical support necessary to break down the barriers and find the hospitalized person a place in the community.
The complex transitions team will continue to check in with the lead agency and the community providers periodically to provide ongoing technical support in the transition back to the community.
For a referral to be made to the complex transitions team, the following eligibility criteria must be met:
The person must currently be on Minnesota Health Care Plan (MHCP), eligible for MHCP or going through the MHCP eligibility application process.
The person must have been in the hospital for more than seven days, with treatment goals complete.
The tribal nation, county, contracted lead agency or MCO care coordinator must have been involved and have exhausted options in seeking community placement or planning for return home: e.g., family home, independent home, community support services, nursing home, etc.
The complex transitions team is not a placement authority. We do not develop placement options and assist with creating services. Nor do we have the authority to mandate that a service provider place a person in their services.
The complex transitions team is not a duplication of other services provided within DHS. Lead agencies will connect with and collaborate with the appropriate area within DHS as usual. The complex transitions team will become involved if help is needed to address barriers to transition to community that cannot be resolved with the existing community resources. The complex transitions team is a way for DHS to observe the overarching barriers and obstacles within the service system as a whole. It will also help all divisions and state agencies to see how we can improve the system as a whole.
