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Program will assist more individuals return home in 2018; community meeting set

WORTHINGTON — A program currently available to help seniors across the state transition from a nursing home facility back home is expanding to serve additional populations.

Beginning in 2018, the Return to Community program will begin serving additional populations by providing resources within their communities that will help allow them remain at home for as long as possible.

“Home can be to an assisted living facility, private home, maybe with a family member — it doesn’t always have to be to their own private home,” said Pam Mailander, community living specialist supervisor, Minnesota River Area Agency on Aging.

Additional populations served will include those who have been discharged from a hospital who are within a set of socioeconomic criteria and concerns have been identified; have completed a physician ordered nursing home stay greater than 90 days; are entering a nursing home for respite stay; consumers who decided not to move to an assisted living after options counseling was provided or are on a waiting list; or have reached the end of Medicare-certified home care and are at risk.

Mailander said the ideal candidate is a private-pay individual and desires in-person assistance.

“The ones on medical assistance already have a case manager helping them to work with those issues,” she added.

The program expansion will also include a medication management program — a new service to current and future consumers. The program provides consumers with medical recommendations made by a team of consulting pharmacists, who also share those recommendations with the consumer's physician. If the physician makes a medication order change, program staff see that the consumer receives the new medication and understands the directions for its use.

Since 2010, Return to Community, a no-cost program under the Minnesota Board of Aging Senior LinkAge Line, has assisted more than 4,000 individuals return to their home after a skilled-nursing facility stay through education and area resources.

A community living specialist meets with a qualifying individual and/or their caregiver face-to-face to begin discussing how they can safely return to the comfort of their own home.

The community living specialist will follow up with the consumer after 72 hours from transitioning home and again after 10 days. The consumer continues to receive follow-up visits, both in-person and over the phone, periodically up to five years after returning home.

“The reason we follow is just to make sure that they’re doing OK and home (and) to see if they need any more resources,” Mailander said.  

Aging from home is not only usually preferred, Mailander said, but there is also a cost-saving benefit.  

“The goal is to help consumers return home and stay at home as long as they’re able and safe, with resources in place,” she said.  

An informational meeting regarding the upcoming expansion will be held from 9 a.m. to 10:30 a.m. Thursday at Ecumen Meadows (1801 Collegeway), Worthington.

The meeting, which will cover how to make referrals, is intended for home care providers, hospital and nursing home discharge planners/social workers, directors of nursing, case managers, home and community-based service providers, health care clinics/homes and health systems.

Those interested may register by emailing Erica Schott, office manager at MInnesota River Area Agency on Aging, at

The southwest region of Minnesota is in the Minnesota River Area Agency on Aging, which with its recent expansion has six community living specialists covering a 27-county region. Offices are located in Mankato and Slayton.

For more information about the Return to Community initiative, visit