Mental Health Nursing Facility Olmstead Navigators Services

The vendor is required to provide for an administrative agent as a third-party case manager to provide case management staff, known as Olmstead navigators, for every nursing facility for mental health (NFMH) resident, approximately 621 individuals across the ten (10) facilities.
• Work with the NFMH residents and guardian and durable power of attorney, if there is legal representation for the NFMH resident to assure their voice is represented in the planning processes. 
• Work with the community mental health center’s (CMHC) NFMH liaisons to obtain access to the CMHC person centered plan (PCP) that includes pre-admission screening and resident review (PASRR) specialized services and transition services (discharge planning). 
• Work with the community developmental disability organizations (CDDO) or intellectual or developmental disability (IDD) service providers for NFMH residents that have an indication of IDD or related condition and need to have IDD services included on the PCP. 
• Work with NFMH staff to obtain access to the nursing facility plan of care. 
• Review both the PCP and the nursing facility plan of care and identify gaps with remedies.
 • Have the ability to use the electronic pre-admission screening and resident review (ePASRR) system for data management when it is available (sfy2026 or sfy2027) for tracking services.
- General administrative functions
1. Third-party case manager
• The third-party case manager, also known as the Olmstead navigator, plays a critical role in enhancing cross-system coordination and fostering collaborative relationships among service providers, with a particular emphasis on clients engaged in or transitioning from nursing facilities for mental health care.
• Operating as a neutral and objective facilitator, the Olmstead navigator ensures that service delivery is integrated, person-centered, and aligned with best practices for continuity of care.
• The Olmstead navigator role is designed to support effective communication and partnership across a diverse array of stakeholders, including CMHCs, NFMHS, CDDOs, managed care organizations (MCOS), social services, educational institutions, and community-based organizations.
• The third-party case manager (Olmstead navigator) actively engages these partners to coordinate plans of care, reduce fragmentation, and promote shared accountability for NFMH resident outcomes.
2. Key responsibilities
• Facilitate meetings with the NFMH, CMHC, and other providers, as needed, to support coordinated care planning for individuals in or transitioning from NFMHS. 
• Serve as a liaison between NFMHS and external service systems such as the CMHCS to ensure continuity and comprehensiveness of care. 
• Monitor implementation of individualized person-centered care plans, NFMH plans of care, and other service plans across multiple providers, identifying service gaps and promoting timely interventions. 
• Support the development of shared goals and responsibilities among stakeholders to improve service alignment and reduce duplication. 
• Advocate for person-centered approaches that prioritize stability, recovery, and long-term success following a stay in an NFMH. 
• Utilize data and progress monitoring tools to track outcomes, inform continuous improvement, and strengthen interagency collaboration.
- Requirements
1. Case management services
• Substance abuse and mental health services administration (SAMHSA) defines case management “as a coordinated approach to the delivery of health, substance abuse, mental health, and social services, linking clients with appropriate services to address specific needs and achieve stated goals” and “… focuses on the whole individual and stresses comprehensive assessment, service planning, and service coordination to address multiple aspects of a client’s life.” (Center for substance abuse treatment, 2000 revision 2015).
• The goal is to transition NFMH residents no longer in need of the NFMH level of services back to the community of their choice and to reduce the length of stay for new residents to less than six months.
• The case management services are for NFMH residents to assure coordination and collaboration among NFMH staff and CMHC NFMH liaisons and CMHC specialized services and, when appropriate, the CDDO or IDD service provider or other service providers.
• Provide the necessary staffing to provide case management to all NFMH residents onsite. 
• Based on the agency for healthcare research and quality, case managers’ caseloads should range between 20-30 residents.
• Total bed capacity across the ten (10) NFMH locations is 621 with an average occupancy rate of 92%.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: July 25, 2025