Helping people move from institutions toward home, independence, and community life that lasts.
For people living in nursing facilities, hospitals, or other institutional settings, the path back to community living can feel overwhelming. There are housing decisions, service gaps, eligibility questions, and coordination challenges that are hard to manage without the right support. Care Crafters exists to bridge that gap. We provide the transition planning, relocation case management, and hands-on coordination that turn a discharge date into a real, sustainable move home.
Through Relocation Service Coordination Targeted Case Management and Minnesota's Moving Home Minnesota demonstration, we help individuals and their families navigate the correct transition pathway, organize key pre move services, coordinate housing and community supports, and strengthen continuity after the move when post transition services are appropriate and authorized.
We don't just plan the discharge. We plan the life after it.
Most institutional transitions fail not because of a bad plan, but because of missing coordination. The housing is not ready. The waiver services are not authorized in time. The person arrives in the community without a primary care provider, without an understanding of their new supports, or without anyone following up to make sure things are actually working.
Care Crafters was built to solve that problem. We stay involved from the first assessment through post-transition follow-up, working directly with the individual, their family, discharge planners, lead agencies, managed care organizations, and community providers to keep the transition moving on a clear timeline. We manage the relocation plan, handle the referrals, track the service authorizations, and stay in communication with everyone who needs to be at the table.
The result is a transition that does not depend on one person remembering to make the right call at the right time. It depends on a coordinated system of support built around the person.
Transition support built around real barriers, not just good intentions.
Successful community transitions require more than referrals and paperwork. They require someone who understands the regulatory landscape, the service delivery timeline, and the practical realities of moving a person from an institution into a stable community setting.
Program specific transition pathways
We support people moving from qualified institutional settings to the community through the transition pathway that fits their eligibility. Depending on the program, that may include hospitals, nursing facilities, ICFs for people with developmental disabilities, and other institution types recognized by the applicable DHS service rules.
Beyond the referral
We do not hand off a list and hope for the best. We coordinate across lead agencies, MCOs, housing providers, and community services, tracking each action item through completion so nothing falls through during the transition window.
Designed for long term success
The measure of a good transition is not the discharge date. It is whether the person is still thriving in the community six months later, with the right services in place and a support structure that holds.
Four coordinated services that cover every stage of the transition journey.
Each service addresses a specific part of the transition from institutional care to community living. Not every service can be used at the same time. The right mix depends on the person's eligibility, whether they are using RSC-TCM or MHM, whether they are on a waiver, and which pre move or post move supports are authorized under DHS rules.
Relocation Service Coordination Targeted Case Management
RSC-TCM is a case management service for individuals preparing to move from an eligible institution into the community. Our case managers develop and maintain the relocation plan, coordinate with the facility discharge team and the receiving community providers, arrange for needed services and housing, and ensure continuity across every stage of the transition. This service includes assessment, planning, referral, coordination, and monitoring activities, all tied to the individual's documented relocation goals.
Moving Home Minnesota Transition Coordination
Through the MHM demonstration, transition coordination brings together every moving part of a community move into a single, organized process. This includes person-centered planning around the individual's preferred living arrangement, coordination with housing providers and landlords, alignment of waiver services and community-based supports, communication with the lead agency and MCO, and the practical logistics of executing a safe, well-timed transition from the facility to the home.
MHM Comprehensive Community Support Services
CCSS is an MHM service a person may choose after moving into the community. It is designed to support successful adjustment to community living through community integration, risk mitigation, and supportive housing activities. It can be used in addition to waiver services when authorized, but it cannot be provided at the same time as Housing Stabilization Services housing sustaining services.
MHM Transitional Services
Transitional services are one time items and expenses that are necessary and reasonable for a person to move from a qualified institution to an MHM qualified community residence. These supports can include furnishings, household supplies, rent deposits, utility setup costs, moving expenses, and other approved housing related start up costs. If a person will enroll in an HCBS waiver and qualifies for waiver transitional services, they must use the waiver version instead of MHM transitional services.
A five-stage process that moves people from institutional care toward stable community living.
Every transition is different, and the exact sequence depends on whether the person is using RSC-TCM, MHM, waiver services, or a combination that DHS allows. In general, strong transitions still follow a clear rhythm, assess needs, build the plan, coordinate the move, execute key pre move tasks, and support stability after the move when post transition services are authorized.
Assess
We evaluate the individual's current setting, eligibility, goals, preferred living situation, existing supports, and the barriers that may affect the transition.
Plan
We develop a relocation plan that documents the services needed, the housing target, the transition timeline, and the responsibilities of each party involved.
Coordinate
We communicate across the facility, lead agency, MCO, housing providers, and community services to align the timeline and close service gaps before the move.
Execute
We manage the logistics of the move itself, ensuring housing is ready, services are authorized and in place, and the individual has what they need from day one.
Stabilize
We follow up post-transition to confirm services are working, address early issues, and support long-term stability so the person stays successfully in the community.
Clear guidance for individuals, families, discharge planners, and referral partners.
These services are designed for people moving from qualified institutional settings to the community through either Relocation Service Coordination Targeted Case Management or the Moving Home Minnesota demonstration. Final eligibility depends on the specific program, the person's institutional setting, level of care, waiver status when relevant, and other DHS criteria.
Individuals and families preparing for discharge
If you or a family member is currently living in a qualified institutional setting and wants to move back into the community, these services may help organize and support that transition through the correct DHS pathway.
- People who need relocation case management or MHM transition coordination before discharge
- People who need help arranging housing, community supports, and move related services
- People on HCBS waivers, and some people transitioning through MHM without a waiver, depending on program eligibility
Discharge planners, lead agencies, and MCO care coordinators
If you work in discharge planning, care coordination, or case management and need a provider who can carry the relocation plan forward with consistency, we are built for that role.
- A transition-focused provider with strong follow-through on relocation plans
- Coordination across housing, services, and waiver authorization timelines
- Clear documentation and communication throughout the transition window
Eligibility for RSC-TCM and MHM is program specific. A person cannot receive MHM and RSC-TCM at the same time. MHM transitional services are generally used only when the person is not on a waiver or does not qualify for waiver transitional services, and MHM CCSS cannot overlap with Housing Stabilization Services housing sustaining services. Care Crafters can help determine which pathway fits the referral.
What every person and family should be able to expect from this process.
Transition work is personal. Behind every relocation plan is a person who wants to live somewhere that feels like home. These are the commitments we hold ourselves to on every case.
Your goals lead the plan
We do not build transition plans around what is fastest or most convenient for the system. We build them around where you want to live, how you want to be supported, and what independence looks like to you.
No surprises, no gaps
You and your family will know what is happening at every stage. We keep discharge teams, lead agencies, and MCOs informed and aligned so the transition does not stall or fall through without warning.
We stay until it holds
The move is not the finish line. We continue coordinating after transition to confirm that services are active, housing is stable, and the supports in place are actually working for the person day to day.
When someone is ready to move home, the right coordination makes all the difference.
Care Crafters provides the relocation case management, transition coordination, and community support services that help individuals leave institutional care and build a stable life in the community. If you are a discharge planner, lead agency, MCO care coordinator, family member, or individual looking for a provider who will carry the transition forward with consistency and care, we are ready to connect.
