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Can standardized assessment contribute to improving Adult Protective Services (APS) practice? In this exploratory study, San Francisco and Napa APS utilized a newly developed short self-neglect assessment to test how standardized measures provide information for substantiation decision making. Findings demonstrated satisfactory reliability and validity for the short self-neglect assessment, and analyses revealed important issues that could improve practice. Review of outliers revealed: (1) problems using the assessment tool, (2) misunderstandings of APS procedures, and (3) struggles navigating the case management system. These revelations could all be easily addressed in training. Caseworker's clinical judgment and experience also continue to have a place in complementing the use of the standardized assessment.

Objectives To provide an estimate and level of uncertainty for Medicaid cost savings due to Minnesota's Return to Community Initiative (RTCI). Design Medicaid cost savings are estimated using a semi-Markov model and simulation approach. Setting and Participants RTCI is a statewide program that assists private paying nursing home residents with discharge to the community. When originally proposed, it was expected that the program would reduce state Medicaid expenditures, primarily through the shifting of residents from nursing homes to a less costly community setting. In prior analysis, we estimated that approximately 1 in 9 residents targeted for transition by the program would not have returned to the community without the RTCI. Accurate cost savings estimates require consideration of complex resident care trajectories, that is, nursing home readmissions, use of assisted living and community-based services, and mortality. Measures Data were from 30,234 private pay nursing home residents admitted during 2011, primarily for post-acute stays, to 378 facilities in Minnesota, and followed for 4 years postadmission for outcomes and time to event. Resident characteristics were taken from the Minimum Data Set (MDS) admission assessment. We modeled variability in care trajectories with a semi-Markov formulation. Transition probabilities were estimated using Multinomial regression. Time to event was modeled using the best-fitting, positive, right-skewed distribution for each path. The simulation was run (1000 times) with and without the RTCI impact to estimate change in Medicaid days in various settings. Results Program savings was estimated at $4.1 million per year of effort over a 4-year accumulation period. Conclusions and Implications The RTCI produced a modest Medicaid cost savings in excess of the annual program budget of $3.5 million. Findings from the semi-Markov model and simulation increase our understanding of care transitions between nursing home, community, Medicaid status, and mortality.

Objectives To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores). Design As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross‐tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed‐effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death. Setting Indiana nursing facilities (N=19). Participants Long‐stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016. Measurements Participant symptoms, transfers, risk factors, and hospital diagnoses. Results We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two‐thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions. Conclusion Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining “avoidability” at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.

Background and objectives Falls are a major source of morbidity and mortality among older adults; however, little is known regarding fall occurrence during a nursing home (NH) to community transition. This study sought to examine whether the presence of supports and services impacts the relationship between fall-related risk factors and fall occurrence post NH discharge. Research design and methods Participants in the Minnesota Return to Community Initiative who were assisted in achieving a community discharge (N = 1459) comprised the study sample. The main outcome was fall occurrence within 30 days of discharge. Factor analyses were used to estimate latent models from variables of interest. A structural equation model (SEM) was estimated to determine the relationship between the emerging latent variables and falls. Results Fifteen percent of participants fell within 30 days of NH discharge. Factor analysis of fall-related risk factors produced three latent variables: fall concerns/history; activities of daily living impairments; and use of high-risk medications. A supports/services latent variable also emerged that included caregiver support frequency, medication management assistance, durable medical equipment use, discharge location, and receipt of home health or skilled nursing services. In the SEM model, high-risk medications use and fall concerns/history had direct positive effects on falling. Receiving supports/services did not affect falling directly; however, it reduced the effect of high-risk medication use on falling (p Discussion and implications Within the context of a state-implemented transition program, findings highlight the importance of supports/services in mitigating against medication-related risk of falling post NH discharge.

In this study, abuse, exploitation, and neglect (ANE) harm was measured by type of abuse using standardized items from the Identification, Services, and Outcomes (ISO) Matrix before Adult Protective Services (APS) interventions (pretest) and after APS interventions (posttest). Change scores from 1,472 older adults (average age 78-year-old; 57% female) and 591 younger adults (average age 53-year-old; 46% female) served by APS during the six months showed reduction of harm using posttest minus pretest. Nonetheless, older adult’s financial abuse harm (pretest=2.2, posttest=1.5) was higher than younger adults’ (pretest=1.5, posttest=1.2), while young adults scored higher in harm on all other types of abuse. Effective interventions differ by age group and by type of abuse, and will be discussed in detail. Results demonstrate the importance to consider vulnerable adult’s age and the etiology of abuse before implementing the services needed to effectively address ANE harm.

OBJECTIVE The objective of this study was to evaluate the impact of Minnesota's Return to Community Initiative (RTCI) on postdischarge outcomes for nursing home residents transitioned through the program. DATA SOURCES Secondary data were from the Minimum Data Set and RTCI staff (January 2015 to December 2016), state Medicaid eligibility files and death records. The sample consisted of 29,201 nursing home discharges in Minnesota occurring in 2015. RESEARCH DESIGN Cox proportional hazard models were used to compare 1-year postdischarge outcomes of nursing home readmission, mortality, and Medicaid conversion for RTCI assisted community discharges and a propensity-matched sample of unassisted community discharges. RESULTS The majority (60%) of RTCI assisted discharges remained alive, in the community and not having converted at Medicaid at 1 year after discharge. Time to mortality was significantly lower for the assisted group than the unassisted group, but time to readmission and Medicaid conversion were similar. CONCLUSION The RTCI assisted residents fared well postdischarge in their time to mortality, nursing home readmission, and Medicaid conversion; they lived longer than a propensity-matched sample of their peers.

OBJECTIVE: To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes. DATA SOURCES: Secondary data were from the Minimum Data Set and RTCI staff (April 2014 – December 2016). The sample consisted of 18 444 non‐Medicaid nursing home admissions in Minnesota remaining for at least 45 days, with high predicted probability of community discharge. STUDY DESIGN: The RTCI facilitates community discharge for non‐Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow‐up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi‐experimental design approach that leverages the programs targeting model. PRINCIPAL FINDINGS: Return to Community Initiative increased community discharge rates by an estimated 11 percent (P

Background. Despite promotion of physical activity guidelines, less than one third of U.S. adults are sufficiently active and an even larger number of older adults fail to meet guidelines. To address this major public health issue, it is essential to broadly consider determinants of physical activity. Aims. This study explores how physical activity behavior is affected by the experience of major life events and considers the stress experienced due to these events across the life course. Method. Nationally representative panel data from the Americans’ Changing Lives survey (1986-2012) was used to analyze a growth model with age-based trajectories to examine the relationship between major life events and physical activity overall and separately by gender and race. Results. In the overall sample, retiring was associated with greater physical activity at baseline. As respondents aged, entering into retirement was associated with decreased physical activity, while a parent or friend dying was associated with greater physical activity. Differences by gender and race were also seen over time. Conclusions. Results show that when considering physical activity trajectories, experiencing these major life events is not always detrimental, and in some cases may be beneficial. Considering these impacts is important in planning effective health promotion interventions to increase and promote maintenance of physical activity, while paying attention to specific differences by gender and race.

Objective assessment is an important tool for Adult Protective Services (APS) in supporting a diverse population. Out of the 1472 APS’ clients, aged 65 and over, assisted during the study period, 39% identified as a non-white race and 30% did not speak English. Providing services to this vulnerable population is made even more difficult by the need to provide culturally appropriate services. In this work, we present on differences in types of abuse alleged, abuse severity assessment, services provided, and preliminary outcomes across racial and language groups. For example, for this population, clients identifying as black race had the highest allegation rates of neglect (16%) and financial abuse (27%), Asians of physical (15%) and emotional abuse (24%), and other races of self-neglect (56%) and isolation (9%). Standardized data collection permits tracking such patterns and objective assessment tools help to avoid systemic bias in aiding this vulnerable population.

Minnesota’s Return to Community Initiative (RTCI) assists private-pay nursing home (NH) residents to return to the community. Using data from a 1-year admission cohort of RTCI-targeted NH residents, we examined why residents who at admission expressed a desire for discharge, were paying privately, and had relatively low-care needs chose to remain in the NH. Characteristics of those who remained were compared with those who discharged using logistic regression, and barriers to discharge were summarized. Residents who were older, more cognitively impaired (OR = 1.8), unmarried (OR = 1.4), had behavior problems (OR = 1.6), or diagnosed with dementia (OR = 2.0) were more likely to remain than discharge to the community. Between admission and their 90-day assessment, residents remaining in the facility had a small decline in cognitive status, yet their continence improved and they became more independent in activities of daily living (ADLs). Seventy-four percent reported a perception of health-related barriers to discharge.

BackgroundAgeing adults are likely to expect informal caregiving assistance from a friend or family member, reflecting the reality that most long-term care (LTC) is provided by family and friends. The purpose of the study was to determine the likelihood that expectations of care will be unmet at the onset of functional disability, and the factors that impact that likelihood.MethodsCommunity-dwelling respondents from biannual repeated assessments (2006–2010) of the Health and Retirement Study over age 65 who expressed a caregiving expectation prior to need were included in the final analytical sample (n=1352). Logistic regression and change models were specified to address impact of variables on unmet expectations.ResultsExpectations of care were unmet for almost one-third (32%) of the sample, among whom 30% were not receiving needed care. Unmet expectations were associated with being unmarried, older and having a higher number of ADL deficits. Change over time in the number of predictor variables influenced the likelihood of unmet expectations.ConclusionsUnplanned dependence on formal care systems and/or having unmet care needs places elders at risk of negative outcomes. Knowledge of factors that impact whether expected care is eventually received provides robust evidence for counselling individuals regarding the need to plan for additional LTC services.

Objective To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. Data Source The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. Data Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. Study Design Mixed effects logistic regression model to predict community discharge. Principal Findings The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. Conclusions Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

Although several states have implemented Value Based Reimbursement (VBR) systems in long-term care; little is known of their impact. In 2016, Minnesota passed new VBR legislation to tie payment to quality with increased funding earmarked for nursing and other care-related services. We evaluated the effect of the policy change on care-related expenditures and measures of care quality. Data sources were cost reports and quality measures for the years 2013-2017 from 348 Minnesota nursing homes. Analysis consisted of descriptive tables, time plots, and linear growth curve modeling. We found increased expenditures for nursing and care-related services, particularly nursing assistants, during the first year; while quality metrics did not appear to be impacted by the policy change. Some differentiation was seen across facilities in their response to the policy change based on occupancy rate, rural-urban continuum code, attachment to a hospital, and resident acuity. The lack of an improvement in care quality might be attributable to VBR design as the quality incentive affected very few facilities. Additionally, there is the challenge of improving quality metrics even with additional resources. The legislature is currently considering changes to VBR policies in response to the report from this study.