Abstract

Objectives: Efforts to rebalance long-term care resources in the US concentrated initially on avoiding nursing admission. Attention is now shifting to community discharge of admitted residents, particularly after a post-acute episode. Several states have introduced programs to promote community discharge; however, evidence of their effectiveness is lacking. Program evaluations have not had rigorous research designs. Also, these programs have targeted individuals who are receiving public assistance (Medicaid) and who could have sizable public costs in either nursing home or community. We report on an evaluation of Minnesota’s Return to Community Initiative (RTCI), an innovative statewide program targeted to private-paying nursing home residents, who are early in their stays but who are at risk of becoming long-stay residents. The goals of RTCI are to promote consumer choice, delay or avoid Medicaid conversion and, ultimately, save public funds. The RTCI staff of Community Living Specialists assists 1200 nursing home residents each year in returning to the community. The study objectives were to: (1) determine the impact of RTCI in transitioning nursing home residents to the community, and (2) compare post-discharge outcomes of RTCI assisted individuals with those leaving without assistance.

Methods: The sample was a 33-month admission cohort of 18,488 residents to 370 Minnesota nursing homes from 2014-2016. Data came from the Minimum Data Set (MDS), standardized assessments performed on all nursing home residents at admission and approximately every 90 days thereafter; and eligibility files, health care claims, and cost figures from state administrative systems. RTCI impact on nursing home use was estimated with a regression discontinuity analysis of community discharges, either with or without RTCI assistance. Post-discharge outcomes of mortality, re-admission to the nursing home, and conversion to Medicaid were examined with proportional hazards analysis comparing a sample of RTCI assisted residents and a propensity matched sample of community discharges without assistance, and comparable residents remaining in the nursing home.

Results: We detected a statistically significant impact on nursing home use. An estimated 11.2% (CI 6.4% to 15.9%) of residents transitioned by RTCI would not have done so without the program. The effect was strongest in nursing homes that most actively participated in RTCI (15.1%) compared to low participants (10.1%) and non-participants (ns). The majority of RTCI transitioned residents remained alive (85%) and in the community (60%). Only 12% of transitioned residents converted to Medicaid in the 12 months after nursing home discharge. Their rates of mortality, nursing home readmission, and Medicaid conversion were not significantly different than a propensity-matched sample of comparable community discharges. However, they had significantly lower mortality and Medicaid conversion than comparable residents remaining in the nursing home.
Conclusions: The RTCI had a modest statistically significant impact in reducing nursing home use by transitioning nursing home residents to the community who would not have done so without RTCI assistance. The majority of transitioned residents fared well; they were alive, living in the community and not enrolled in Medicaid at 12 months after discharge. A follow-up analysis estimated Medicaid cost savings at $3.9 Million annually.