Targeting Residents for Transitions from Nursing Home to Community

Objective To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community. Data Sources Secondary data from minimum data set (MDS) assessments for an annual cohort of first-time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006. Study Design We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; resident's preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence. Principal Findings At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low-care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates. Conclusions A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short-stay residents are at risk of becoming long-stay residents.