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

描述（由申请人提供）：我们提出了明尼苏达州返回社区计划（RCP）的协作，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。它集中在那些希望离开养老院的人，还没有医疗补助资格，并且在养老院停留60到90天。这些人有可能长期住在疗养院并转为医疗补助。RCP工作人员为居民和家庭照顾者提供咨询和过渡规划，协助他们进行过渡，并通过每90天的后续评估监测他们在社区的情况。该计划试图避免不必要的住院或疗养院重新入院。此外，RTC使用各种战略，使养老院参与过渡过程。我们的研究将实现这些目标。1.评估RCP在增加居民向社区过渡、减少疗养院使用、延迟个人向医疗补助的转换、避免对过渡居民产生意外的负面影响（例如，增加住院率、艾德使用率或疗养院再入院率），并实现医疗补助节省。2.评估RCP的促进和维持过渡的程序流程：（a）ADRC工作人员的居民定位，咨询，过渡规划和后续行动的方法;（B）护理之家参与计划和部署护理之家工作人员实现过渡目标;（c）过渡和家庭照顾者对计划的看法。3.在整个3年的研究中，以迭代方式将评价结果应用于项目改进。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AHRQ的卫生服务和研究示范和传播赠款（R18）RFA。来自印第安纳州大学（IU）和明尼苏达大学（UMN）的多学科研究团队具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，将使用定量和定性方法进行研究。他们将与明尼苏达州人类服务部（DHS）和BoA的同事合作，他们设计和管理返回社区计划。

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.