Information for Family Care and IRIS Staff


Connections to Community Living is a Department of Health Services, Division of Long Term Care, initiative to help support choice to live in the community for individuals currently living in nursing homes and other institutional settings. The long term care system in Wisconsin has renewed efforts to assist individuals and families in transitioning to the least restrictive and most community integrated setting. Aging and Disability Resource Centers (ADRCs) provide options counseling and, if eligible for Medical Assistance, enrollment counseling. The process identifies barriers to relocation and assists in developing a plan to return home and to the community. For persons eligible for public benefits, ADRCs assess for functional eligibility using the functional screen. This information is forwarded to the Managed Care Organization (MCO)/IRIS consultant agency following enrollment counseling.

MCO teams and IRIS consultants work with the individual and their families to develop a person-centered transition plan based on preferences and cost effectiveness, identifying supports already available to the individual and additional service needs.

For certain relocations, the Department receives an enhanced federal MA match under the Money Follows the Person (MFP) Demonstration. Persons eligible are those with longer term stays in the nursing home, (90 days in the nursing home, not counting Medicare rehabilitation days), who transition to community integrated settings, such as a home or apartment, and adult family home of four beds or less, or certain Residential Care Apartment Complexes (RCACs). ADRCs explain MFP to eligible residents enrolling in family care/IRIS and obtain informed consent from those who agree to participate. Prior to transition, MCOs/IRIS consultants administer a Quality of Life survey and report relocation information to the MFP demonstration staff.

Some counties have been identified as areas with large numbers of Medicaid funded nursing home residents (PDF 46 KB). Community Living Specialists (CLSs) are assigned to these areas to assist the ADRCs with outreach and information to nursing home residents and nursing home staff. Like the ADRCs, CLSs meet with persons who answer yes to the nursing home MDS assessment Section Q "Do you want to talk to someone about the possibility of returning to the community?" They help families and other supports identify issues and concerns that affect health and safety and may assist in meeting with care teams and the person-centered planning process. They may supplement the work of the care teams/consultants as requested to ensure a successful transition.

As part of the outreach to nursing home residents, ADRCs and the CLSs give information to nursing home residents who may not know that community living is an option. They discuss community resources and housing options with persons who no longer have a home to return to. They meet with spouses and other family members to discuss caregiving options and other available supports so that a person can return home. They act as an advocate on behalf of the individual to ensure choice and preference, and to live as independent as possible. CLSs also meet with new admissions to support discharge plans already in place and provide resource information as needed.

Connections to Community Living is a program supported through the MFP Demonstration Grant. CLSs may assist ADRCs in discussing MFP and obtaining informed consent to participate, and care managers in administering the MFP Quality of Life survey, as requested.

Links to helpful resources:

Last Revised: July 6, 2015