NURSING FACILITY TRANSITION SERVICES PROVIDER IN OREGON

Fatumata Kaba
Oct 6
4 min read

SUPPORTING INDIVIDUALS IN SAFELY RETURNING TO COMMUNITY LIVING WITH DIGNITY, CHOICE, AND COMPREHENSIVE SUPPORT

Nursing Facility Transition (NFT) Services in Oregon are Medicaid-funded supports designed to help individuals residing in nursing homes or institutional settings move back into the community. These services assist with care planning, housing navigation, home setup, and coordination of home and community-based services (HCBS). NFT is delivered through Oregon’s Medicaid programs — primarily the Oregon Health Plan (OHP) — under the K Plan (1915(k)), HCBS Waivers, and specialized transition initiatives such as Oregon’s Money Follows the Person (MFP) program.

1. GOVERNING AGENCIES

Agency: Oregon Department of Human Services (ODHS) – Aging and People with Disabilities (APD)

Role: Manages transition planning, funding approval, and coordination through local offices and transition coordinators.

Agency: Oregon Health Authority (OHA)

Role: Oversees Medicaid administration, provider enrollment, and quality compliance under the Oregon Health Plan.

Agency: Centers for Medicare & Medicaid Services (CMS)

Role: Provides federal oversight for transition programs and ensures compliance with Money Follows the Person and HCBS rules.

Agency: Oregon Secretary of State (SOS)

Role: Registers provider businesses operating in Oregon.

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

NFT Services are designed to help eligible Medicaid beneficiaries transition from institutional care to independent or supported living settings. Providers work closely with discharge planners, case managers, and families to support a safe and sustainable move.

Approved providers may deliver:

Transition Planning & Coordination: Collaborating with facilities and case managers to develop a step-by-step discharge and support plan.
Housing Search & Setup: Identifying appropriate housing options, assisting with applications, and arranging utilities.
One-Time Transition Supports: Purchasing basic furnishings, appliances, and supplies to establish a new home.
Caregiver Training & Family Support: Educating caregivers on service needs, medication management, and safety.
Linkage to HCBS Services: Referring to providers for personal care, homemaker services, nursing, or behavioral supports.
Follow-Up Monitoring: Checking in post-transition to ensure stability and service access.
Documentation: Service plans, purchase logs, visit notes, and Medicaid billing records.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register your business with the Oregon Secretary of State.
Obtain an EIN from the IRS and a Type 2 NPI.
Enroll as a Medicaid provider through the OHA Provider Portal.
Apply for approval as a transition service provider through ODHS/APD.
Carry general liability and workers’ compensation insurance.
Develop a Nursing Facility Transition Policy & Procedure Manual based on state transition standards.

4. OREGON PROVIDER ENROLLMENT PROCESS

Step 1: Register business and secure an EIN, NPI, and insurance.

Step 2: Apply for Medicaid enrollment via OHP’s Provider Portal.

Step 3: Contact ODHS/APD for transition service approval and staff background checks.

Step 4: Submit your policy manual, transition protocols, and documentation templates.

Step 5: Once approved, coordinate with transition coordinators and begin receiving referrals.

5. REQUIRED DOCUMENTATION

Business registration and Articles of Incorporation
EIN and NPI confirmation
Insurance certificates
ODHS/APD approval
Nursing Facility Transition Policy & Procedure Manual, including:
- Discharge and housing planning workflows
- Emergency preparedness protocols
- Service delivery and documentation guidelines
- Staff training policies and coordination checklists
- Consent forms and participant rights policies
- Item purchase logs and transition tracking forms
- Medicaid billing forms and follow-up visit logs

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Case Manager

Requirements: Background check; training in Medicaid HCBS, housing navigation, and client-centered planning.

Role: Program Supervisor

Requirements: Oversees service quality, monitors outcomes, and liaises with facilities and ODHS.

Role: Support Aides (optional)

Requirements: Assist with move-in setup, shopping, and home preparation.

All staff must complete:

HIPAA and confidentiality training
Abuse prevention and incident reporting
Medicaid documentation protocols
Housing support and safety training
Annual performance reviews and continuing education

7. MEDICAID WAIVER PROGRAMS

NFT Services are funded under:

K Plan (1915(k)) – includes transition planning and one-time setup costs.
APD Waivers – for seniors and adults with physical disabilities transitioning to HCBS.
IDD Waivers (Comprehensive and Support Services) – for individuals with IDD transitioning from institutional or foster care settings.
Money Follows the Person (MFP) Program – special funding initiative for those in facilities 60+ days.
State Plan Medicaid (limited) – may cover basic transition coordination services.