The former program name included both “transition” and “diversion,” and those words still help explain two common starting points. A transition usually describes a member leaving a nursing facility for assisted living. Diversion describes a person living elsewhere who is at risk of needing institutional care and may be able to live safely in an assisted living setting instead. The destination can look similar; the records, timeline and risks are often different.
Same destination, different starting point
Do not force every case into a nursing-facility discharge story. Current DHCS criteria also contemplate eligible members in community and short-term settings.
The transition pathway
A member in a nursing facility may have an established care team, medication administration record, therapy notes and a documented level of care. That can make the clinical story easier to see, but discharge planning still requires a safe receiving setting, the member’s agreement and coordination across providers.
Long stays also create practical issues: belongings may be elsewhere, housing may have been given up, and family roles may have changed. A good plan addresses more than transportation on discharge day.
The diversion pathway
A person at home, in subsidized housing, in a hospital or in a short-term skilled stay may be at risk of institutionalization. The challenge is often proving the level and pattern of need across scattered records. Families may describe “decline,” while the reviewer needs concrete information about bathing, transfers, medications, cognition, supervision and recent incidents.
Diversion is not a shortcut around plan review. The proposed RCFE must still be appropriate, and the plan must determine that the member meets the service criteria.
Information that helps either pathway
The strongest referral tells a coherent story: where the person is now, what assistance is needed, what changed, why the current setting is no longer workable, what the member prefers and how the proposed assisted living setting would address the risk.
Specific examples are more useful than broad labels. “Needs help” becomes “requires hands-on assistance to transfer from bed to walker and has fallen twice in the last month.” “Memory issues” becomes “misses evening medication unless prompted and attempted to leave the home at night.”
- Current diagnoses and medication list
- Functional needs and recent changes
- Recent hospital, emergency or skilled-nursing use
- Safety incidents and supervision needs
- Member preferences and proposed setting
Why timing differs
A facility discharge date may create urgency, but it does not erase authorization or admission requirements. A diversion case may have more calendar flexibility, yet waiting until a crisis can compress the same work into a few days. In both cases, begin the conversation while there is still time to compare safe options.
Ask the current care team which facts are already documented and which assessments are still pending. Parallel work—plan review, RCFE screening and family financial planning—can reduce dead time without assuming approval.
The question that keeps planning grounded
Keep asking: “What would have to be true for this person to live safely in an RCFE?” The answer should cover care needs, staffing, equipment, behavior support, medication management, payment and backup plans. If any part is unresolved, it becomes an action item rather than a hopeful assumption.
For the step-by-step workflow, see From Hospital or SNF to an RCFE.
Sources & important note
Zeal reviewed the primary sources below while preparing this article. Policies, benefits and individual circumstances can change; confirm current requirements with the responsible agency, health plan and licensed provider.
- DHCS: Community Supports Policy Guide, Volume 1
- CMS: Discharge Planning Checklist for patients and caregivers
- California Department of Aging: Assisted Living Facilities
Editorially reviewed September 2026.