Key Partners

• Colorado Department of Health Care Policy & Financing or HCPF (state Medicaid agency)
• Local Contact Agencies (LCAs) – Community-based organizations, often area agencies on aging (AAAs) and aging and disability resource centers (ADRCs)
• Transition Coordination Agencies (TCAs) – TCAs can also be LCAs 

LCAs provide the initial education to nursing facility residents about transitions to the community. They send referrals to TCAs to start the process if the resident wants to explore transitions. The TCAs process the transition referrals and support residents with setting up services and completing assessments to ensure a smooth transition.

Overview

Colorado’s In-Reach Counseling Program is designed to connect residents living in nursing facilities with the information and resources they need to make informed decisions about their community living options. Through both individual and group counseling sessions, the program supports residents in understanding available community-based services, housing options, and the steps required to transition successfully out of nursing facilities.

Group In-Reach Counseling

Group In-Reach counseling sessions are conducted in nursing facilities and led by trained In-Reach Counselors. These sessions provide residents and their natural supports with accessible information about available community support while also encouraging open dialogue and shared exploration of transition options. Natural supports are individuals such as family, friends, or neighbors identified by the resident and invited to attend at the discretion of the resident.

Group In-Reach sessions offer a supportive group environment where individuals can offer shared experiences, ask questions, and explore decision-making among participants experiencing similar challenges. These group-based sessions not only provide education around housing and support services, but also serve as a direct referral point for Individual In-Reach (IIR) and transition coordination services. Each session typically includes:

• An overview of available home and community-based services (HCBS), including waiver programs and eligibility requirements and general information on Health First Colorado (Medicaid) for individuals who are not enrolled
• Key elements of long-term services and supports (LTSS), including the role of these services in supporting individuals with daily activities in their home or community settings, the importance of person-centered care planning, and the coordination between nursing facilities and transition coordinators to ensure continuity of care
• State and local resources, including housing, food access, caregiver support, and diagnosis-specific services
• Transition timelines and expectations when moving from an institutional setting to the community
• Referrals to TCAs such as AAAs, ADRCs, and other agencies or IIR counseling and transition support.

Program Impact & Investment

In-Reach Counseling’s referral process benefits all parties involved, including:

• Residents: Ensures individuals’ rights by providing timely, comprehensive, and relevant information that allows them to make informed decisions about transitioning to the community.
• Skilled Nursing Facilities (SNFs): Supports more timely post-rehabilitation transitions and increases staff awareness of community-based supports and partnership opportunities.
• TCAs and LCAs: Strengthens relationships with SNFs, case management agencies, and Regional Accountable Entities (Managed Care Organizations for Health First Colorado), while maintaining sustainable contracts with HCPF supported by state funds.
• HCPF: Demonstrates use of person-centered practices through documented outreach efforts and ensures that residents who choose to transition have the support and infrastructure they need to do so successfully.

As of December 2025, Colorado has implemented Group In-Reach in 100 percent of nursing facilities across the state. The In-Reach Counselors met with 1,518 individuals across 183 SNFs in Colorado, resulting in 521 referrals for Individual In-Reach or transition coordination. The work is supported by state general funds, Medicaid administrative claiming, and Money Follows the Person.

Next Steps

The state continues to look for ways to expand the program by adding additional TCAs, LCAs, and referral sources. Implementation of Individual In-Reach began in July of 2025 with the goal of engaging all members in a Medicaid nursing facility by December 2026