This course is intended for Transition Navigators (TNs) and individuals who are involved in the Community Transition Services (CTS) process. It will provide TNs with the knowledge and resources required to assist CTS beneficiaries who are transitioning out of the Nursing Facility and back into the community. The Michigan Department of Health and Human Services (MDHHS) CTS Team developed this course with the assistance of the Michigan State University Institute for Health Policy.

Module 1: Introduction to CTS

Module 2: Medicaid Programs, Application Process and Eligibility

Module 3: The Long-Term Services and Supports (LTSS) Continuum

Module 4: Advocacy and Nursing Facility Basics

Module 5: Person-Centered Planning

Module 6: Community Transition Services Cycle

Module 7: Overcoming Barriers

Module 8: Post Transition Activities

Module 9: Congratulations

• Are community transition services new to you and you wish to learn more?
• Have you wondered if there is more to community transition services than you know?
• Did you know that people who are admitted to a hospital may be eligible for community transition services?
• Do you have an interest in becoming a Transition Navigator and want to learn more?
• Are you a Transition Navigator, but are interested in understanding your roles and responsibilities during the Community Transition Services Process?
• Does learning how to better serve your Community Transition Services beneficiaries sound intriguing to you?

• Understand the history of Community Transition Services (CTS) and eligibility requirements.
• Identify the various Medicaid Coverages, how to apply, and eligibility requirements for CTS.
• Become familiar with the Long-Term Services and Supports Continuum and the various home and community based services options available to CTS beneficiaries.
• Develop a basic understanding of the individuals and their roles within and out of the Nursing Facility that may be included throughout the CTS process.
• Understand the basics of CTS documentation, person-centered planning and the elements of completing a strong Community Transition Assessment.
• Become familiar with Transition Navigator’s role during the planning, implementation and cycle of CTS.
• Learn about common barriers to discharging from the nursing facility and potential ways to overcome them.
• Gain an understanding of the roles related to a Transition Navigator after a beneficiary has transitioned back to the community.