Understanding Colorado’s TCM‑TC Program: How Transition Coordination Supports Successful Community Living

Transitioning from a nursing facility or institutional setting back into the community is a major life change—one that requires planning, coordination, and the right supports at the right time. Colorado’s Targeted Case Management – Transition Coordination (TCM‑TC) program was designed to make that process safer, smoother, and more person‑centered for adults who want to return home.

At Love Foundation 303 Ltd., we specialize in TCM‑TC and Home & Community‑Based Services (HCBS), helping members navigate every step of the transition with dignity, clarity, and confidence.

What Is TCM‑TC?

TCM‑TC is a Medicaid benefit offered through the Colorado Department of Health Care Policy & Financing (HCPF). It provides non‑clinical, administrative coordination to help individuals safely transition from long‑term care facilities into community settings.

This service focuses on:

• Gathering assessments and documentation

• Coordinating with hospitals, nursing facilities, and community providers

• Identifying risks and developing mitigation strategies

• Supporting discharge planning

• Ensuring continuity of care once the member returns home

  
  

TCM‑TC is free to eligible Medicaid members and is built around person‑centered planning, choice, and self‑determination.

Why TCM‑TC Matters

Leaving a facility is more than a move—it’s a full life transition. Members often need help with:

• Housing navigation

• Benefits coordination

• Accessing HCBS services

• Understanding risks and supports

• Communicating with multiple providers

• Preparing for daily living needs in the community

  
  

Without structured coordination, these steps can feel overwhelming. TCM‑TC ensures no one has to navigate them alone.

How Transition Coordination Works

A Transition Coordinator (TC) partners with the member to:

1. Complete Required Assessments

This includes gathering information from the ULTC 100.2, CCM assessments, and other documentation needed to determine eligibility and support needs.

2. Identify Risks & Strengths

TCs work with the member to understand potential risks—such as health concerns, financial limitations, or past challenges living independently—and build a Risk Mitigation Plan (RMP) where appropriate.

3. Build a Person‑Centered Transition Plan

This plan outlines the member’s goals, preferences, supports, and the steps needed for a safe transition.

4. Coordinate With Providers

The TC communicates with hospitals, nursing facilities, HCBS providers, housing partners, and community resources to ensure everyone is aligned.

5. Support the Move Home

From arranging services to confirming equipment delivery, the TC helps ensure the member is ready for community living.

TCM‑TC and HCBS: A Powerful Combination

While TCM‑TC focuses on transition planning, HCBS provides the ongoing supports that help members thrive once they’re home.

Together, they create a continuum of care that includes:

• Life skills training

• Homemaker and personal care services

• Behavioral supports

• Transportation coordination

• Community access

• Health and wellness monitoring

This combination helps members build stability, independence, and long‑term success.

Who Qualifies for TCM‑TC?

Members may be eligible if they:

• Are currently living in a nursing facility or institutional setting

• Have Medicaid

• Express a desire to return to the community

• Require coordination to support a safe transition

  
  

TCM‑TC is voluntary and centered on the member’s goals and readiness.

Our Commitment to Person‑Centered Transitions

At Love Foundation 303 Ltd., we believe every transition should honor the member’s voice, culture, and lived experience. Our team:

• Uses trauma‑informed, strengths‑based practices

• Communicates clearly with all providers

• Builds plans that reflect real‑life needs

• Ensures compliance with HCPF standards

• Supports members long after the move home

  
  

We don’t just coordinate services—we walk alongside each person as they rebuild their independence.

Ready to Learn More?

If you or someone you support is exploring a transition back to the community, the next step is to connect directly with HCPF’s In‑Reach team. They can explain eligibility, answer questions, and help determine whether TCM‑TC is the right fit.

To request information or begin the process, simply click here. Once submitted, an In‑Reach specialist will follow up to provide guidance and walk you through what to expect.

If you would like to work specifically with Love Foundation 303 Ltd., you can tell the In‑Reach specialist directly during your conversation. When a member expresses that preference, HCPF will route the referral to us so we can support your transition.