NURSING FACILITY TRANSITION SERVICES PROVIDER IN SOUTH CAROLINA

Fatumata Kaba
Oct 13
3 min read

SUPPORTING SAFE, PERSON-CENTERED TRANSITIONS FROM INSTITUTIONAL CARE TO HOME AND COMMUNITY SETTINGS FOR MEDICAID RECIPIENTS

Nursing Facility Transition Services (NFTS) help individuals leave nursing homes or institutional settings and re-establish residence in their homes or the community. These services are authorized under South Carolina Medicaid’s Home and Community-Based Services (HCBS) Waivers, including the Community Long Term Care (CLTC) program and the Money Follows the Person (MFP) initiative. They focus on reducing institutional reliance and promoting independence, dignity, and self-directed living.

1. GOVERNING AGENCIES

Agency: South Carolina Department of Health and Human Services (SCDHHS)

Role: Administers HCBS waivers and oversees funding, service eligibility, and provider enrollment.

Agency: South Carolina Department of Disabilities and Special Needs (DDSN)

Role: Coordinates transitions for waiver participants with IDD under applicable waivers.

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

Role: Oversees the Money Follows the Person (MFP) program and ensures state compliance with federal transition standards.

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

NFTS help participants plan, fund, and coordinate their move out of institutional care. Services include comprehensive planning, home setup, and connections to supportive services after discharge.

Approved providers may deliver:

Transition Planning & Coordination
Housing Search & Lease Assistance
Home Setup & Environmental Modification
Purchase of Basic Household Goods (e.g., beds, cookware, hygiene products)
Utility Deposits & Start-Up Fees
Coordination of In-Home Services (personal care, transportation, etc.)
Follow-Up Support for 90 Days Post-Discharge
Documentation: Transition plan, service logs, purchase receipts, Medicaid billing forms

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register your business with the South Carolina Secretary of State
Obtain EIN and Type 2 NPI
Enroll with SCDHHS as a Transition Services provider or apply as a CLTC case management partner
Hire qualified transition coordinators or case managers
Develop a Nursing Facility Transition Services Policy & Procedure Manual
Maintain liability insurance and vendor compliance for household purchases

4. SOUTH CAROLINA PROVIDER ENROLLMENT PROCESS

Step 1: Register your business and obtain necessary tax IDs

Step 2: Submit a provider enrollment application to SCDHHS or through the CLTC provider network

Step 3: Submit resumes, training documentation, and policy manual for review

Step 4: Complete readiness review and receive provider credentials

Step 5: Begin accepting referrals from CLTC or waiver case managers

5. REQUIRED DOCUMENTATION

Articles of Incorporation, EIN, and NPI
Provider enrollment confirmation from SCDHHS
Insurance documents
Policy & Procedure Manual covering:
- Transition planning workflows
- Housing and community resource coordination
- Purchasing and reimbursement tracking
- Critical incident and follow-up procedures
- HIPAA and participant rights
- Medicaid billing compliance tools

6. STAFFING REQUIREMENTS

Role: Transition Coordinator

Requirements:

Experience in case management, housing support, or waiver navigation
Background check, CPR/First Aid, and HIPAA training

Role: Program Supervisor (optional)

Requirements: Oversees service quality, documentation, and follow-up procedures

All staff must complete:

Participant rights and confidentiality training
Crisis planning and emergency relocation protocol
Medicaid documentation and billing training
In-service training on housing barriers and benefits coordination

7. MEDICAID WAIVER PROGRAMS

Nursing Facility Transition Services are authorized through:

CLTC (Community Long Term Care) – Primary program coordinating nursing home discharges
Money Follows the Person (MFP) – Federal initiative funding transitional costs
ID/RD Waiver & HASCI Waiver – Transition coordination for individuals with IDD or brain injuries
Community Supports Waiver – May include transition supports based on assessed needs
State Plan Medicaid – Covers follow-up services like personal care, home health, or durable medical equipment

8. TIMELINE TO LAUNCH

Phase: Business Setup & Manual Development

Timeline: 1–2 months

Phase: Medicaid Enrollment & Provider Training

Timeline: 2–3 months

Phase: Staff Hiring & Community Network Building

Timeline: 1–2 months

Phase: Referral Intake & Transition Planning

Timeline: Upon SCDHHS approval and CLTC coordination

9. CONTACT INFORMATION

South Carolina Department of Health and Human Services (SCDHHS)

Website: https://www.scdhhs.gov

Centers for Medicare & Medicaid Services (CMS) – MFP Program

Website: https://www.medicaid.gov/medicaid/ltss/money-follows-person/index.html

South Carolina Department of Disabilities and Special Needs (DDSN)

Website: https://ddsn.sc.gov

SOUTH CAROLINA NURSING FACILITY TRANSITION PROVIDER

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — SC NURSING FACILITY TRANSITION PROVIDER

WCG supports providers in developing compassionate, cost-effective transition programs that reduce institutional care reliance and promote community reintegration.

Scope of Work: