Oregon Nursing Facility Transition Services (NFTS) Policy Manual
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The Oregon Nursing Facility Transition Services (NFTS) Policy Manual outlines the comprehensive standards and procedures for assisting eligible individuals in safely and successfully transitioning from institutional settings—such as nursing facilities or state hospitals—into integrated community-based living arrangements. Aligned with the Oregon Administrative Rules (OAR 411-035), the HCBS Settings Rule (42 CFR §441.301), and the Olmstead Decision, this manual ensures transitions uphold individual choice, autonomy, and full community inclusion.
The manual covers critical transition components such as eligibility verification, informed choice documentation, housing acquisition, financial management, service coordination, and post-transition supports. It defines the roles and responsibilities of transition specialists and providers in securing essential resources including housing, furnishings, adaptive equipment, and personal care supplies. Additionally, it ensures safeguards such as emergency preparedness planning, client rights protections, and culturally responsive practices, especially for tribal members (in accordance with SB 13).
Detailed protocols also address housing coordination, landlord partnerships, environmental modifications, and benefits navigation. Post-transition follow-up strategies are included to reduce recidivism, ensure continued community integration, and promote long-term stability.
The NFTS Policy Manual serves as a regulatory and operational guide for Medicaid waiver providers, case managers, state-contracted specialists, and housing support professionals. It promotes person-centered, conflict-free case management and ensures compliance with federal and state requirements while maintaining a focus on dignity, self-direction, and cost-effective service delivery.