SNF-to-Home Transition Program Saves $3.9M Annually

Programs that help nursing home residents transition back into their communities can make all the difference in helping them return home safely. And home-based care providers often play an important role in that process.

That’s according to a recent study published in the journal Health Services Research.

Conducted by researchers from Purdue University, University of Minnesota and Harvard Medical School, the study examines the state of Minnesota’s Return to Community Initiative (RTCI), a statewide program to help private-pay nursing home residents return to the community and stay there without converting to Medicaid.


The RTCI program helps non-Medicaid nursing home residents by assisting with discharge planning, transition back into the community and post-discharge follow-up. Often, that planning includes home care or home health care.

“Home health or home care is one of the top service areas individuals assisted through the program were being connected with,” Zachary Hass — an assistant professor at Purdue University’s schools of nursing, an industrial engineering and the lead author of the study — told Home Health Care News.

As part of the study, Hass and fellow researchers evaluated the impact of RTCI on community discharges for nursing home residents, looking to determine the program’s direct impact.


Researchers examined the data of more than 18,000 Minnesota nursing home residents who were admitted into nursing home settings between 2014 and 2016, who were non-Medicaid at admission and who remained in the nursing home for at least 45 days.

Overall, researchers found that an estimated 11% of nursing home residents assisted by RTCI would have remained in the nursing home long-term without the program.

Additionally, the study found that the program saved $3.9 million annually over a four-year period. The annual budget was $3.5 million for the services across Minnesota.

“The program is effective in helping nursing home residents return home,” Hass said. “They are able to stay in the community for a meaningful amount of time, and all of this without costing the state additional money.”

The success of Minnesota’s RTCI and similar programs could mean more referrals for in-home providers.

The program utilizes home-based care providers to ensure a safe return to the home, according to Hass, who also serves as core faculty for the Regenstrief Center for Health Care Engineering at Purdue.

Over the years, health care policymakers have attempted to curb spending by moving care into the home.

“Around 80% of individuals assisted through the program were needing that type of service for some length of time,” Hass said. “Home health plays a crucial role in making the return to community possible, opening the door for many older adults with lower care needs to receive that care in the place they prefer, at a much cheaper cost than in a nursing home.”

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