The Colorado Department of Health Care Policy & Financing said it will begin a limited pilot of a new, data‑driven “at risk” diversion process intended to identify Medicaid members living in the community who show characteristics that increase the likelihood of nursing‑facility placement and provide targeted outreach to help them remain in the community.

The department said the model is part of its Department of Justice agreement and must be approved by the monitor and DOJ before it is finalized. Jill Schnatterst, Compliance and Innovation Division Director, said the methodology combines stakeholder input, literature review and statistical modeling of past admissions to create a risk score that weights factors such as age, living arrangement (partner/no partner), prior nursing‑facility stays, multiple hospitalizations and chronic conditions including diabetes, serious mental illness, stroke and dementia.

“The risk scores let us kind of balance all of those out to identify the people who are most at risk and provide that outreach,” Schnatterst said. She emphasized the model remains under DOJ review and some components may change during that approval process.

The program’s stated goal is to “ensure that Medicaid members living in the community and that are identified as at risk for institutionalization by the department have the supports and services that they need to remain in a community setting of their choice,” Victoria Lewis, an in‑reach coordinator, told attendees. Lewis added the at‑risk designation will trigger additional outreach by case management agencies and transition coordination staff before a potential institutional admission. She also said participation is voluntary: “this is not a mandatory service, so members have the right to opt out or decline of any at risk support or services at any time.”

Who is included and how they are routed: Lewis said the department will assign members enrolled in home‑and‑community‑based services (HCBS) to their case management agency (CMA) and non‑HCBS members to another referral channel. Schnatterst said the initial population meeting the agreement criteria will be Medicaid‑enrolled individuals over age 21 with a physical disability; the department will publish more detail on the Health Care Policy & Financing Long‑Term Supports and Services website after DOJ approval.

Pilot size, schedule and referrals: The department plans to distribute the first at‑risk list after Jan. 31 and is aiming for February or March for the initial outreach, pending approval, Lewis said. Lists will be distributed quarterly and the department plans a much smaller initial list than previously expected — roughly 200 to 250 members statewide, divided among CMAs and other referral partners. Lewis said the department will provide advance notice of the exact distribution date.

Referral and service timelines: Nora, a department staff member who presented the TCMTC diversion procedures, described the referral workflow and time frames for targeted case management diversion (TCMTC) services. Under the described process, the department’s transitions administrator forwards an at‑risk diversion referral to a transition coordination agency (TCA); the TCA has one day to respond to the referral, two business days to meet with the member after acceptance, and seven business days to complete a diversion plan. The diversion plan includes a streamlined risk‑mitigation plan and documents housing preferences, community supports and steps to avoid facility admission. Nora said TCMTC diversion services continue until the member’s risk level is reduced to medium or low and that services are intended only when the CMA or other local provider cannot meet the member’s needs.

Training and evaluation: The department plans TCMTC at‑risk diversion training for TCAs later in the month and said it will review the model annually and adjust the algorithm as real‑world data come in. Schnatterst said any changes tied to the DOJ agreement will require monitor and DOJ review.

Questions from stakeholders focused on the scope of CMA and RAISE supports, housing capacity and how options counselors and local contact agencies fit into the process. In response, presenters said the referral form will indicate the specific needs that triggered referral (for example, housing assistance) so the receiving agency can identify whether the CMA or a TCA should provide services. Lewis said a separate outside referral process for members not on the initial list is under development for a later phase.

Why it matters: The department framed the pilot as a targeted, research‑based effort to reduce avoidable institutional placement by connecting the most at‑risk Medicaid members with in‑community supports earlier. Because the model is part of the DOJ settlement and requires monitor approval, the rollout depends on external review and the department’s planned quarterly lists and evaluation cycle.

Looking ahead: The department said it will publish methodology details and program materials on its Long‑Term Supports and Services web page once approved, offer training for TCAs, and continue stakeholder engagement while the pilot is piloted and refined.