Regional Discharge PlannersWorking together to solve

transition issues

Maddy Forsberg, Program Director Minnesota River Area Agency on Aging

(MNRAAA)

July 18, 2006 Duluth MN

Minnesota Rural Health Conference

How We StartedLong Term Care Reform

1. Maximize peoples’ ability to meet their own long-term care need

2. Expand capacity of community long-term care system3. Reduce Minnesota’s reliance on the institutional model of

long-term care4. Align systems to support high quality and good outcomes5. Support the informal network of families, friends and

neighbors6. Recruit and retain a stable long-term care work force

• Planning and Development Activities– Funding for counties to undertake planning

and development activities related to the LTC system.

• Gaps Analysis • Service Development Plan

Legislative Requirements

Gaps Analysis

– Analyze the long-term care needs of community members

– Obtain a comprehensive understanding of gaps in services and create and implement a development plan to meet the housing and service needs and preferences of seniors

– Create and implement a development plan to meet the housing and service needs and preferences of seniors

Service Development Plan

– Addendum to the County’s Community Social Services Act plan (CSSA plan) due Dec 2001

– Maximize peoples ability to meet their own LTC needs

– Expand capacity of the Community– Reduce reliance of institutional modal– Align systems to support high quality and

good outcomes– Support the informal network– Recruit and sustain long term care workforce

Gaps Analysis Process

• Counties (9) contracted with AAA• AAA conducted focus groups and community

meetings.– Public Health / Family Services– Housing– Transportation, respite chore and adult day– Minorities– Faith communities– Veterans– Chambers – Hospitals– Local elected officials

Gaps Analysis Process cont.

• Reviewed data• Submitted report to DHS-11/15/01• Service Development Plan 12/31/01• Regional Analysis 12/31/01• Updates 12/31/04• Reports by county and regionally located on

DHS website http://www.dhs.state.mn.us/main/groups/aging/documents/pub/dhs_id_005807.hcsp

Major Findings of Gaps Analysis

– Information/Assistance, in-home respite, insurance counseling/forms assistance, caregiver training as a high need;

– guardianship/conservatorship as a high need; – home delivered meals and mental health as a

high need; – service coordination, transportation, out-of-

home respite, companion services and skilled nursing as a high need.

Identified through meetings

Common elements of many of the findings were discharge planner issues

– Inconsistent discharge planning processes– Common tools for discharge planning– Issues of transition– Need for local education for discharge planners– Problem solving and issues discussion among peers

Accomplishments

– Formed a Region discharge planning Group– Quarterly meetings– Common Protocols for discharge– Flow Charts– Regional Training with Stratis Health

• Essential of Discharge Planning• Health Literacy

– Community Resource Education

Accomplishments cont.

– Chronic Care Elderly Intervention Project PW– Education on Drug discount Cards and

Medicare Part D– Grants

• Availability• Grantwriting 101 by Bremer

– Legislative Issues– Volunteer Respite Program– CMS Guidelines for reporting VA incidents

Accomplishments cont.

– Volunteer Based Nursing Home Transition Teams

– Barriers to Service Clients– SNF Medicare Beneficiary Notice– Transit coordination– Reverse Mortgages Information– Arthritis– Home design and safety Issues

Message

Healthcare is more than a hospital, nursing home, clinic, or home care.

It is all.

It should include quality professional and informal care.