Regional Discharge Planners
Working 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 Started
Long Term Care Reform
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Maximize peoples’ ability to meet their own long-term care
need
Expand capacity of community long-term care system
Reduce Minnesota’s reliance on the institutional model of longterm care
Align systems to support high quality and good outcomes
Support the informal network of families, friends and neighbors
Recruit and retain a stable long-term care work force
Legislative Requirements
• Planning and Development Activities
– Funding for counties to undertake planning
and development activities related to the LTC
system.
• Gaps Analysis
• Service Development Plan
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.
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Public Health / Family Services
Housing
Transportation, respite chore and adult day
Minorities
Faith communities
Veterans
Chambers
Hospitals
Local elected officials
Gaps Analysis Process cont.
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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-ofhome respite, companion services and skilled
nursing as a high need.
Identified through meetings
Common elements of many of the findings were
discharge planner issues
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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.