Return to Community Initiative
What is the Return to Community Initiative?
A new initiative that includes federal and state long-term care rebalancing efforts, known as Return to
Community, passed the 2009 Minnesota Legislature. The service begins April 1, 2010. The initiative is
targeted to nursing home residents who express a desire to return to the community and/or have a support
person to assist with their transition. It is a comprehensive initiative across multiple programs of the
Minnesota Department of Human Services Continuing Care in partnership with the federally designated
Aging and Disability Resource Center initiative, known as the MinnesotaHelp Network™ which is
administered by the Minnesota Board on Aging.
Aging and Disability Resource Center (ADRC)
The Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AoA) are supporting
initiatives in all states called the Aging and Disability Resource Centers (ADRCs). In Minnesota this effort is
branded, the MinnesotaHelp Network™. These efforts are specifically designed to divert and/or transition
consumers so that they can remain in the community by connecting them to a service called long-term care
options counseling. This initiative is considered a key component of federal rebalancing efforts along with
nursing home diversion and health promotion strategies.
Who will be the focus of Return to Community?
Return to Community is targeted to nursing home residents who:
1. Are early in their nursing home stay (90 days or less from admission)
2. Have the desire and/or support to return to the community
3. Fit a community discharge profile that indicates a high probability of community discharge
4. Would otherwise become long stay residents
How will Return to Community be implemented?
The approach:
The Return to Community initiative has two general approaches:
1. Providing intervention through a formal transition program targeted to nursing home residents who have
expressed a desire to return to the community. The intervention will involve assessment, care planning,
service coordination, placement, and ongoing monitoring of care in the community; and
2. Providing interventions that motivate and support nursing home providers to facilitate discharge to the
community through their own efforts or in cooperation with formal transition programs. The support
provided with the proposed interventions will assist nursing facility providers in meeting the Centers for
Medicare & Medicaid (CMS) requirements to plan and make referrals to a designated agency to assist
those residents indicating a desire to return to the community.
There are critical long-term care changes occurring nationwide and in Minnesota that will interface with the
Return to Community initiative. The converging of these with the Return to Community initiative will provide
consumers with streamlined, easy to access, person-centered long-term care options planning and
counseling statewide.
Who will provide the Return to Community service?
Return to Community is an evidence based, consumer driven service provided locally by MinnesotaHelp
Network™ Community Living Specialists. The specialists are part of the network that includes the Minnesota
Board on Aging Senior LinkAge Line® and www.MinnesotaHelp.info. Both are part of the broader
MinnesotaHelp Network™ which is the Aging and Disability Resource Center (ADRC) model for Minnesota
that also includes the Disability Linkage Line®, Veterans Linkage Line™, and other community based
partners.
MinnesotaHelp Network™ Community Living Specialist will target private pay residents of nursing homes to
avoid duplication of services. These are protocols in place to connect managed care and Medical
Assistance enrollees with appropriate parties.
MinnesotaHelp Network™ Community Living Specialists will assist nursing home residents with transitioning
from the nursing home to the community. A unique feature of the Return to Community initiative is that
follow-up assessments will be completed for a number of years with the individuals who are transitioned
from the nursing home to track their success or failures.
MinnesotaHelp Network™ Community Living Specialists will provide intensive support activities including:
 Long-term Care Options Counseling
 Evaluation
 Support planning
 Service coordination
 Follow-up for 5 years
 Documentation in secure web-based portal.
Return to Community goals
1. Focus on residents and families
 Begin discharge planning at nursing home admission
 Equip consumers with self-care skills
 Support family caregivers
 Line up community resources.
2. Partnerships with public agencies, nursing homes, hospitals, managed care plans, and other health care
providers.
Return to Community is an evidence based approach
Return to Community, an evidence-based model, is based on research conducted under contract to DHS by
the University of Minnesota School of Public Health and the Indiana University Center for Aging Research.
The report included a review of the Minimum Data Set data and a literature review supporting a model for
developing a community discharge profile. It also included criteria to assist the state in identifying savings
that would result from a concerted effort at intervention with nursing facility residents.
The research examined community discharge patterns in Minnesota nursing facilities. Several key factors
were identified resulting in four targeting criteria that increase the probability of a person’s community
discharge:
1. First-time nursing home admission without a history of prior nursing home use.
2. Fall into targeting windows:
 Early stage interventions at 90-179 days
 Targeted case management interventions after 180 days.
3. Prefer to return to the community and/or have a person who is supportive of community discharge.
4. Fit a short-stay community discharge profile – health and functional conditions at admission that increase
the probability of a successful community discharge.
The research is based on probability of discharge. In reviewing a resident’s health, functional, and
demographic characteristics and his/her preferences for care setting, it is possible to predict at admission
how likely he/she will be to return to the community or remain in the nursing home until death.
Changes to Minimum Data Set (MDS)
Effective Oct. 1, 2010, the Centers for Medicare and Medicaid Services (CMS) is scheduled to replace the
current federally prescribed health functional assessment of nursing home residents, known as the Minimum
Data Set (MDS). The new MDS 3.0 will include data collection and information requirements for consumers
offering options for returning to community life in the least restrictive and most integrated setting.
On admission to a nursing facility and with the annual and quarterly assessments, the nursing facility will be
required to ask a person if they would like to speak with someone to learn about the possibility of returning
to the community and options for community supports and services. If the individual answers yes, the
nursing facility is required to act on this request through care planning and referral. The nursing facility shall
initiate care planning and contact the designated entity in the State so that they can meet with the resident to
discuss community transition possibilities and options for services and supports. The designated entity in the
State is presumed to be the Aging and Disability Resource Center (ADRC) which is the MinnesotaHelp
Network™ in Minnesota.
Return to Community Materials
On March 18th 2010, the Minnesota Department of Human Services and the Minnesota Board on Aging
sent a joint letter to each Minnesota nursing home administrator about the “Return to Community” initiative.
On July 8th 2010 an initial supply of “Return to Community” brochures were provided to each Minnesota
nursing home along with a joint letter from the Minnesota Department of Human Services and the Minnesota
Board on Aging about how the brochure should be utilized with all new admissions. The brochure is also
available through the statewide Senior LinkAge Line® by calling 1-800-333-2433.
How can I get more information?
For additional information follow the links below.
 Road Show March 2010 Powerpoint handout
 Return to Community handout
 Return to Community Statute MN Statute 256.975 subd 7