Return to Community Initiative

What is the Return to Community Initiative?

A new initiative that includes federal and state long-term care rebalancing efforts, known as Return to Community, passed the 2009 Minnesota Legislature. The service begins April 1, 2010. The initiative is targeted to nursing home residents who express a desire to return to the community and/or have a support person to assist with their transition. It is a comprehensive initiative across multiple programs of the Minnesota Department of Human Services Continuing Care in partnership with the federally designated Aging and Disability Resource Center initiative, known as the MinnesotaHelp Network™ which is administered by the Minnesota Board on Aging.

Aging and Disability Resource Center (ADRC)

The Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AoA) are supporting initiatives in all states called the Aging and Disability Resource Centers (ADRCs). In Minnesota this effort is branded, the MinnesotaHelp Network™. These efforts are specifically designed to divert and/or transition consumers so that they can remain in the community by connecting them to a service called long-term care options counseling. This initiative is considered a key component of federal rebalancing efforts along with nursing home diversion and health promotion strategies.

Who will be the focus of Return to Community?

Return to Community is targeted to nursing home residents who:
1. Are early in their nursing home stay (90 days or less from admission)
2. Have the desire and/or support to return to the community
3. Fit a community discharge profile that indicates a high probability of community discharge
4. Would otherwise become long stay residents

How will Return to Community be implemented?

The approach:

The Return to Community initiative has two general approaches:

1. Providing intervention through a formal transition program targeted to nursing home residents who have expressed a desire to return to the community. The intervention will involve assessment, care planning, service coordination, placement, and ongoing monitoring of care in the community; and

2. Providing interventions that motivate and support nursing home providers to facilitate discharge to the community through their own efforts or in cooperation with formal transition programs. The support provided with the proposed interventions will assist nursing facility providers in meeting the Centers for Medicare & Medicaid (CMS) requirements to plan and make referrals to a designated agency to assist those residents indicating a desire to return to the community.

There are critical long-term care changes occurring nationwide and in Minnesota that will interface with the Return to Community initiative. The converging of these with the Return to Community initiative will provide consumers with streamlined, easy to access, person-centered long-term care options planning and counseling statewide.

Who will provide the Return to Community service?

Return to Community is an evidence based, consumer driven service provided locally by MinnesotaHelp Network™ Community Living Specialists. The specialists are part of the network that includes the Minnesota Board on Aging Senior LinkAge Line® and www.MinnesotaHelp.info. Both are part of the broader MinnesotaHelp Network™ which is the Aging and Disability Resource Center (ADRC) model for Minnesota that also includes the Disability Linkage Line®, Veterans Linkage Line™, and other community based partners.

MinnesotaHelp Network™ Community Living Specialist will target private pay residents of nursing homes to avoid duplication of services. These are protocols in place to connect managed care and Medical Assistance enrollees with appropriate parties.
MinnesotaHelp Network™ Community Living Specialists will assist nursing home residents with transitioning from the nursing home to the community. A unique feature of the Return to Community initiative is that follow-up assessments will be completed for a number of years with the individuals who are transitioned from the nursing home to track their success or failures.

MinnesotaHelp Network™ Community Living Specialists will provide intensive support activities including:

  • • Long-term Care Options Counseling
  • • Evaluation
  • • Support planning
  • • Service coordination
  • • Follow-up for 5 years
  • • Documentation in secure web-based portal.
  • Return to Community goals

    1. Focus on residents and families

  • • Begin discharge planning at nursing home admission
  • • Equip consumers with self-care skills
  • • Support family caregivers
  • • Line up community resources.
  • 2. Partnerships with public agencies, nursing homes, hospitals, managed care plans, and other health care providers.

    Return to Community is an evidence based approach

    Return to Community, an evidence-based model, is based on research conducted under contract to DHS by the University of Minnesota School of Public Health and the Indiana University Center for Aging Research. The report included a review of the Minimum Data Set data and a literature review supporting a model for developing a community discharge profile. It also included criteria to assist the state in identifying savings that would result from a concerted effort at intervention with nursing facility residents. 

    The research examined community discharge patterns in Minnesota nursing facilities.  Several key factors were identified resulting in four targeting criteria that increase the probability of a person’s community discharge:

    1. First-time nursing home admission without a history of prior nursing home use.
    2. Fall into targeting windows:

  • • Early stage interventions at 90-179 days
  • • Targeted case management interventions after 180 days.
  • 3. Prefer to return to the community and/or have a person who is supportive of community discharge.
    4. Fit a short-stay community discharge profile – health and functional conditions at admission that increase the probability of a successful community discharge.
  • The research is based on probability of discharge. In reviewing a resident’s health, functional, and demographic characteristics and his/her preferences for care setting, it is possible to predict at admission how likely he/she will be to return to the community or remain in the nursing home until death.

    Changes to Minimum Data Set (MDS)

    Effective Oct. 1, 2010, the Centers for Medicare and Medicaid Services (CMS) is scheduled to replace the current federally prescribed health functional assessment of nursing home residents, known as the Minimum Data Set (MDS). The new MDS 3.0 will include data collection and information requirements for consumers offering options for returning to community life in the least restrictive and most integrated setting.

    On admission to a nursing facility and with the annual and quarterly assessments, the nursing facility will be required to ask a person if they would like to speak with someone to learn about the possibility of returning to the community and options for community supports and services. If the individual answers yes, the nursing facility is required to act on this request through care planning and referral. The nursing facility shall initiate care planning and contact the designated entity in the State so that they can meet with the resident to discuss community transition possibilities and options for services and supports. The designated entity in the State is presumed to be the Aging and Disability Resource Center (ADRC) which is the MinnesotaHelp Network™ in Minnesota.

    Return to Community Materials

    On March 18th 2010, the Minnesota Department of Human Services and the Minnesota Board on Aging sent a joint letter to each Minnesota nursing home administrator about the “Return to Community” initiative.

    On July 8th 2010 an initial supply of “Return to Community” brochures were provided to each Minnesota nursing home along with a joint letter from the Minnesota Department of Human Services and the Minnesota Board on Aging about how the brochure should be utilized with all new admissions. The brochure is also available through the statewide Senior LinkAge Line® by calling 1-800-333-2433.

    How can I get more information?

    For additional information follow the links below.


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