Discharging Nursing Facility Residents with Mental Health Diagnoses to the Community: Who Leaves, Who Returns, and What Is the Role of Social Work

Background and Purpose: Federal and state initiatives including Money Follows the Person (MFP) grants and Medicaid Home- and Community-Based waiver services have increased the capacity for individuals to receive long-term care services in the setting they choose. Individual's preference for care provided in the community coupled with the high cost of nursing facility (NF) care have encouraged efforts to discharge individuals with Medicaid from NFs to community settings. Of particular interest are older adults with mental health diagnoses who discharge and have unique needs for mental health and aging services. To aid in increasing discharges for this population, we utilized a mixed methods approach. We examined the characteristics of a sample of Medicaid NF residents with mental health diagnoses who discharged to the community, analyzed their discharge and reentry patterns, and identified strategies used by social workers to facilitate these successful discharges. Methods: We conducted a secondary analysis of NF admission and discharge assessments utilizing the Minimum Data Set (MDS). We selected a sample of Medicaid residents, with diagnoses of anxiety, bipolar, or schizophrenia, who entered an NF and discharged to a community setting between July 1, 2005 and June 30, 2008. Informed by an ecological model, we described the sample in terms of physical and cognitive health attributes, informal supports, and utilization of community services. In addition, we investigated the sample's transition patterns for up to 3 ½ years and used logistic regression to predict whether residents had one versus multiple transitions. Finally, we conducted in-depth interviews with NF social services staff to identify strategies used to facilitate discharge among this population. Results: In three years, 720 Medicaid individuals with a mental health diagnosis discharged from an NF to a community setting (e.g., private home or assisted living). The sample represented a broad range of functioning in activities of daily living and cognition. Analysis of NF and community transition patterns indicated that 61% had only one stay in the NF during the study period, though more frequent patterns of entry and discharge occurred. Logistic regression results (Nagelkerke R² = .156) pointed to dynamic relationships among factors that predict NF and community transition patterns. For example, interactions between presence of chronic disease and depression were statistically significant (Wald = 4.67; OR = 3.24; p<.05). Finally, NF social workers utilized multifaceted approaches for discharging residents to the community, including: educating residents and informal caregivers on how to manage physical and mental health diagnoses effectively, building relationships with community services and mental health services staff to assist residents in getting needed services, and advocating for resident decision-making throughout the process. Conclusion and Implications: These findings demonstrate that individuals with diverse mental health needs are discharging from NFs to community settings, and among those who discharge, the occurrence of reentry is relatively low. Social workers can play a key role in increasing discharge rates if sufficient time is allotted for this role by using the discharge strategies identified in this study.