Study of a State-Level Model for Transitioning Nursing Home Residents to the Comm

描述（由申请人提供）：我们提出了一项明尼苏达回归社区计划（RCP）的合作，混合方法研究。RCP是一项创新的国家级干预措施，旨在促进养老院居民向社区的过渡。它主要针对那些希望离开养老院的人，他们还没有医疗补助资格，并且在养老院呆了60到90天。这些人冒着长期住在养老院和转向医疗补助的风险。RCP工作人员为居民和家庭照顾者提供选择咨询和过渡计划，帮助他们进行过渡，并通过每90天的随访评估来监测他们在社区中的情况。该计划试图避免不必要的住院或疗养院再次入院。此外，RTC使用各种策略让养老院参与过渡过程。我们的研究将达到这些目的。1. 评估RCP在增加居民向社区过渡、减少养老院使用率、延迟个人向医疗补助转换、避免对过渡居民产生意想不到的负面影响（例如，住院率、急诊科使用率或养老院再入院率增加）和实现医疗补助节省方面的结果。2. 评估RCP促进和维持过渡的项目流程：(a) ADRC工作人员对住院患者的定位、咨询、过渡计划和后续行动的方法；(b)养老院参与计划和部署养老院工作人员实现过渡目标；(c)过渡和家庭照顾者对该计划的看法。3. 在整个3年的研究中，以迭代的方式将评估结果应用于程序改进。4. 向州医疗补助计划、adrc、护理机构和其他长期护理机构传播研究结果，以帮助他们制定有效的过渡计划。该研究响应了AHRQ的卫生服务和研究示范和传播赠款（R18） RFA。来自印第安纳大学（IU）和明尼苏达大学（UMN）的多学科研究团队拥有丰富的长期护理经验和对明尼苏达州长期护理系统的深入了解，将采用定量和定性相结合的方法进行研究。他们将与设计和管理“重返社区”项目的明尼苏达州人类服务部和美国银行的同事合作。

DESCRIPTION (provided by applicant): We propose a collaborative, mix-method study of the Minnesota Return to Community Program (RCP). RCP is an innovative state-level intervention that promotes transition of nursing home residents to the community. It concentrates on individuals who wish to leave the nursing home, are not yet Medicaid eligible, and whose stay in the nursing home is between 60 and 90 days. These are individuals who risk a long-term nursing home stay and conversion to Medicaid. The RCP staff members give residents and family caregivers options counseling and transition planning, assist them in making the transition, and monitors their situation while in the community through follow-up assessments every 90 days. The program attempts to avoid unnecessary hospitalizations or nursing home re-admission. Also, the RTC uses a variety of strategies to engage nursing homes in the transition process. Our study will achieve these aims. 1. Evaluate the RCP's outcomes in increasing resident transitions to the community, reducing nursing home utilization, delaying individual conversions to Medicaid, avoiding unintended negative consequences for transitioned residents (e.g., increased hospital admissions, ED use, or nursing home readmissions) and achieving Medicaid savings. 2. Assess the RCP' program processes for promoting and sustaining transitions: (a) ADRC staff's approaches to resident targeting, counseling, transition planning, and follow-up; (b) nursing home engagement in the program and deployment of nursing-home staff toward transition goals; (c) transitioned and family caregiver view's of the program. 3. Appl evaluation findings to program improvement in an iterative fashion throughout the 3 years of the study. 4. Disseminate study findings to state Medicaid programs, ADRCs, nursing facilities and other long-term care settings to assist them in developing effective transition programs. The study responds to AHRQ's Health Services and Research Demonstration and Dissemination Grants (R18) RFA. A multidisciplinary research team from Indiana University (IU) and University of Minnesota (UMN) having extensive long-term care experience and in- depth knowledge of the Minnesota long-term care system will carry out the study using a mixture of quantitative and qualitative methods. They will collaborate with colleagues at the Minnesota Department of Human Services (DHS) and BoA who designed and administer Return to Community Program.