Buttke Darci, Cooke Valerie, Abrahamson Kathleen, Shippee Tetyana, Davila Heather, Kane Rosalie, Arling Greg
Minnesota Board on Aging, Saint Paul, MN 55101, USA;
Valerie Cooke, Minnesota Department of Human Services, Saint Paul, MN 55101, USA;
Geriatrics (Basel). 2018 Jun;3(2):18. doi: 10.3390/geriatrics3020018. Epub 2018 Apr 10.
Minnesota's Return to Community Initiative (RTCI) is a novel, statewide initiative to assist private paying nursing home residents to return to the community and to remain in that setting without converting to Medicaid. The objective of this manuscript is to describe in detail RTCI's development and design, its key operational components, and characteristics of its clients and their care outcomes. Data on client characteristics and outcomes come from the Minimum Data Set, staff assessments of clients and caregivers, and Medicaid eligibility files. Most clients transitioned by the RTCI had entered the nursing facility from a hospital. Clients overwhelmingly wanted to return to the community and fit a health and functional profile making them good candidates for community discharge. Most clients went to a private residence, living alone or with a spouse; yet, adult children were the most frequent caregivers. At one year of follow-up 76% of individuals were alive and living in the community and only a small percentage (8.2%) had converted to Medicaid. The RTCI holds promise as a successful model for states to adopt in assisting individuals who are at risk to become long stay nursing home residents instead to return to the community.
明尼苏达州的“回归社区倡议”（RTCI）是一项全新的全州性倡议，旨在帮助自费入住养老院的居民回归社区，并在不转为医疗补助的情况下继续留在社区生活。本文的目的是详细描述RTCI的发展与设计、关键运营要素、客户特征及其护理结果。有关客户特征和结果的数据来自最低数据集、工作人员对客户及护理人员的评估以及医疗补助资格档案。RTCI促成过渡的大多数客户是从医院进入护理机构的。绝大多数客户希望回归社区，且其健康状况和功能状况表明他们适合出院后回归社区。大多数客户回到私人住所，独居或与配偶同住；然而，成年子女是最常见的护理人员。在随访一年时，76%的人存活且生活在社区，只有一小部分（8.2%）转为接受医疗补助。RTCI有望成为一个成功模式，供各州采用，以帮助那些有成为长期入住养老院居民风险的人回归社区。
