261802 Promoting Transitions from Nursing Home to Community in the Minnesota Return to Community Program

Tuesday, October 30, 2012 : 4:54 PM - 5:06 PM

Greg Arling, PhD , Regenstrief Institute, Indiana University Center for Aging Research, Indianapolis, IN
Kathleen Abrahamson, PhD, RN , Department of Public Health, Western Kentucky University, Bowling Green, KY
Emmy Lee, BS , Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN
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.

Learning Areas:
Conduct evaluation related to programs, research, and other areas of practice
Program planning

Learning Objectives:
Design a program to facilitate community transitions for nursing home residents desiring to return the community and could appropriately be served there. Evaluate the impact of this program on nursing home utilization, conversion to Medicaid, and Medicaid expenditures.

Keywords: Nursing Homes, Evaluation

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am an established researcher in aging and public health and was primarily responsible for the design anf analysis for this study.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.