Promoting Transitions from Nursing Home to Community in the Minnesota Return to Community Program

Minnesota's Return to Community (RTC) is an innovative data-driven statewide program that promotes transitions from nursing home (NH) to community for individuals early in their NH stays (60-90 days) who desire discharge, fit a community discharge profile based on health and functional conditions, are at risk for Medicaid spend-down, and would likely remain in the facility and become long-stay without the program. The goals of RTC are to prevent unwanted and unnecessary NH use, increase consumer choice, delay or avoid Medicaid conversion and save Medicaid and private funds. Case managers provide comprehensive assessments before discharge and periodically thereafter. Active care planning supports the community transition. We describe the RTC design and present initial RTC evaluation findings. Minnesota's 370 NHs have 48559 admissions annually. Seventy percent of admissions are discharged within 60 days with 77% of these discharges returning to the community. Among the 14789 NH residents remaining at 60 days, 35% (N=5222) meet RTC targeting criteria. At baseline prior to RTC implementation, 27% of targeted residents were discharged to the community in 60-90 days; 42% were in the NH at 90 days and 19% remained in the NH for at least 1 year. Community discharge rates varied widely across facilities and local NH markets. The large number of targeted individuals with continued NH use after 90 days presents ample opportunity for RTC intervention. The RTC, which is still ramping up, has actively transitioned over 300 residents. We discuss implementation challenges, lessons learned, and planned longitudinal analyses of program impact.