Relocation Service Coordination Targeted Case Management
RSC-TCM is a case management service built specifically for individuals preparing to leave an eligible institution and move into community living. At Care Crafters, our case managers take ownership of the relocation plan from initial assessment through post-transition follow-up, coordinating across facility discharge teams, lead agencies, MCOs, housing providers, and community service organizations to ensure nothing is missed during the transition window.
This is not general case management. It is transition-specific, time-sensitive coordination designed to move a person from an institutional setting into a stable community placement with the right services authorized and in place before the move happens.
The five core case management activities that drive every successful relocation.
RSC-TCM is structured around five federally recognized case management functions. Each activity is documented, tied to the individual's relocation goals, and carried out with the consistency and follow-through needed to keep the transition on track.
Assessment
We evaluate the individual's current institutional setting, community living preferences, service needs, strengths, and the specific barriers that could affect a successful transition.
Planning
We develop and maintain the written relocation plan, documenting the housing target, services to be arranged, responsible parties, timelines, and the person's stated goals for community living.
Referral & Linkage
We connect the individual to the community providers, housing resources, medical services, and waiver supports they will need once the move is complete, and follow each referral through to confirmation.
Coordination
We communicate across discharge planners, lead agencies, MCO care coordinators, housing contacts, and service providers to keep every party aligned on timing and the transition plan.
Monitoring
We track progress throughout the transition, identify issues early, adjust the relocation plan as needed, and continue follow-up after the move to confirm services are active and the placement is stable.
Transition coordination that closes gaps instead of creating them.
Many transitions stall or fail because no one is managing the full picture. The facility is focused on discharge. The lead agency is focused on authorization. The housing provider is waiting on a timeline. RSC-TCM exists to connect those pieces into a single, coordinated process.
Building the relocation plan
We begin working with the individual and the facility team as early as possible, sometimes months before a target discharge date. During this phase, we complete the initial assessment, draft the relocation plan, identify housing options, begin service referrals, and open communication lines with the lead agency and MCO. The goal is to have every major element in motion before the transition window opens.
Managing the move
As the discharge date approaches, coordination intensifies. We confirm housing readiness, verify that service authorizations are in place, ensure the individual has what they need for move-in day, and stay in direct contact with the discharge team and community providers. We track every open item and follow up on anything that has not been confirmed.
Confirming stability
RSC-TCM does not end at discharge. After the move, we continue monitoring to confirm that services are active, the living arrangement is stable, the individual is adjusting, and any early issues are addressed before they become crises. This post-transition period is often where the difference between a lasting placement and a return to institutional care is determined.
Documentation and accountability
Every assessment, plan update, referral, coordination contact, and monitoring activity is documented in accordance with Medicaid requirements. Our case managers maintain detailed, timely records that support both compliance and continuity of care across the entire transition.
Eligibility, institutional settings, and the people who benefit most.
RSC-TCM is available to individuals who are currently residing in an eligible institutional setting and are preparing to transition into community living. Eligible institutions generally include nursing facilities, hospitals with extended stays, and intermediate care facilities, though specific eligibility criteria depend on the individual's circumstances, waiver enrollment, and length of institutional stay.
This service is particularly valuable for individuals who have complex service needs requiring coordination across multiple providers, people whose transitions involve housing search and setup, and situations where the discharge planning process involves multiple systems that need to communicate effectively.
Referrals can come from facility discharge planners, lead agencies, MCO care coordinators, county social workers, family members, or the individuals themselves. If you are unsure whether someone qualifies, Care Crafters can help assess the situation and advise on the best path forward.
If you are a discharge planner, lead agency, or MCO care coordinator looking for a provider to carry the relocation plan forward, we welcome the conversation. We respond to referrals quickly and can begin coordination as soon as authorization is in place.
Ready to begin a relocation plan? Let's connect.
Whether you are an individual, a family member, or a referral partner, Care Crafters is ready to begin the coordination work that makes a successful community transition possible.
