NURSING FACILITY TRANSITION SERVICES PROVIDER IN RHODE ISLAND

Fatumata Kaba
Oct 9
4 min read

SUPPORTING INDIVIDUALS TO SAFELY TRANSITION FROM INSTITUTIONAL CARE TO INDEPENDENT, COMMUNITY-BASED LIVING WITH DIGNITY AND CHOICE

Nursing Facility Transition (NFT) Services in Rhode Island assist individuals in moving from nursing homes or institutional settings back into the community. These Medicaid-funded services are designed to support older adults and individuals with disabilities who are eligible for Home and Community-Based Services (HCBS) but require planning, coordination, and support to successfully live in a home or residential setting. NFT services are available under Rhode Island’s Medicaid 1115 Waiver and managed through the Executive Office of Health and Human Services (EOHHS), Long-Term Services and Supports (LTSS), and Medicaid Managed Care Organizations.

1. GOVERNING AGENCIES

Agency: Rhode Island Executive Office of Health and Human Services (EOHHS)

Role: Administers Medicaid-funded transition programs, oversees provider enrollment and payments.

Agency: Nursing Facility Transition Coordinators / Medicaid MCOs

Role: Coordinate discharge planning and refer individuals for transition services.

Agency: Centers for Medicare & Medicaid Services (CMS)**

Role: Regulates Medicaid HCBS transition services and 1115 demonstration programs.

Agency: Rhode Island Department of Health (RIDOH)**

Role: Licenses providers if offering home health, personal care, or housing support components as part of transition.

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

NFT Services support individuals preparing to leave a nursing facility and reintegrate into the community by addressing housing, personal supports, environmental accessibility, and care coordination.

Approved providers may deliver:

Individualized Transition Planning: Housing search, benefit applications, and discharge coordination.
Community Support Setup: Linking individuals with in-home care providers, adult day services, or Medicaid waivers.
Housing Stabilization Services: Security deposit, utility setup, or short-term tenancy support (when authorized).
Home Modifications & Equipment Coordination: Ensuring safety and accessibility post-discharge.
Life Skills Coaching: Budgeting, grocery shopping, medication self-management.
Follow-Up Support: Regular visits to ensure stability and service continuity post-transition.
Documentation: Transition plan, service log, and billing records.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register your business entity with the Rhode Island Secretary of State.
Obtain a Federal EIN and Type 2 NPI.
Enroll as a Medicaid provider for Home and Community-Based Services (HCBS) under NFT codes.
If providing direct care (e.g., homemaker, personal care, clinical), obtain RIDOH licensure.
Maintain liability, workers’ comp, and general business insurance.
Develop a Nursing Facility Transition Policy & Procedure Manual compliant with EOHHS and CMS guidelines.

4. RHODE ISLAND PROVIDER ENROLLMENT PROCESS

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

Step 2: Enroll in the Medicaid provider portal and apply for NFT-related service codes.

Step 3: Contract with Medicaid MCOs or referral networks handling transition coordination.

Step 4: Submit documentation including your manual, staff resumes, and service structure.

Step 5: Upon approval, begin receiving referrals for transition candidates.

5. REQUIRED DOCUMENTATION

Articles of Incorporation and business registration
EIN and NPI confirmations
Medicaid enrollment confirmation
RIDOH licensure (if applicable to care components)
Nursing Facility Transition Policy & Procedure Manual including:
- Transition planning workflows and checklists
- Housing coordination and referral documentation
- Post-discharge follow-up and service monitoring
- Risk mitigation and safety planning procedures
- Client rights, privacy policies, and HIPAA compliance
- Medicaid billing templates and transition reporting forms

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Case Manager

Requirements: Experience with discharge planning, community resources, and Medicaid benefits.

Role: Housing Specialist (optional)

Requirements: Knowledge of rental navigation, vouchers, and tenant-landlord negotiation.

Role: Direct Support Worker or HHA (if providing in-home support)

Requirements: Background check, CPR/First Aid, and training in ADL assistance.

All staff must complete:

HIPAA and participant rights training
Risk mitigation and emergency planning training
Housing and benefits coordination education
Documentation and Medicaid billing training
Cultural competency and trauma-informed care (recommended)

7. MEDICAID WAIVER PROGRAMS

NFT Services are authorized through:

Global Consumer Choice Compact 1115 Waiver (RI Medicaid): Includes NFT supports under HCBS.
LTSS Managed Care (MCOs): Transition services integrated into case management contracts.
Developmental Disability Waivers (via BHDDH): Include transitions for eligible individuals with ID/DD.
Money Follows the Person (MFP) Demonstration (if reactivated): Formerly provided enhanced transition supports.

8. TIMELINE TO LAUNCH

Phase: Business Formation & Manual Development

Timeline: 1–2 months

Phase: Medicaid Enrollment & RIDOH Licensing (if needed)Timeline: 2–3 months

Phase: Staff Hiring, Training & Readiness Prep

Timeline: 30–60 days

Phase: Referral Activation & Service Start

Timeline: Begins after enrollment and referral network setup

9. CONTACT INFORMATION

Rhode Island Executive Office of Health and Human Services (EOHHS)

Website: https://eohhs.ri.gov

Rhode Island Medicaid Provider Portal

Website: https://www.riproviderportal.org

Rhode Island Department of Health (RIDOH) – Licensure Info

Website: https://health.ri.gov/licenses

Centers for Medicare & Medicaid Services (CMS)

Website: https://www.cms.gov

RHODE ISLAND NURSING FACILITY TRANSITION SERVICES PROVIDER

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — RHODE ISLAND NFT SERVICES PROVIDER

WCG supports new and existing providers in Rhode Island launching Medicaid-authorized transition services that bridge institutional and community-based care.

Scope of Work: