In 2019, Elderbridge launched an Iowa Return to Community (IRTC) pilot program in 6 counties to help seniors successfully transition from hospitals or long-term care facilities back to their homes. However, shortly thereafter, the program was suspended as the COVID-19 pandemic spread and states began implementing shelter-in-place orders. During the pandemic, Elderbridge collaborated with meal sites to ensure food delivery to homebound participants and introduced GrandPad Tablets and robotic pets to address social isolation among older adults. Despite the pandemic's impact later in 2021, Elderbridge reopened its offices and resumed offering services including the IRTC. In FY23, the IRTC expanded to 3 additional counties.
The Brown University Center for Gerontology and Health Care Research (2021) shows that the percentage of low-acuity nursing facility residents in Iowa is 15.8%, well above the national average of 9.9%. In rural nursing facilities in Iowa, the rate surpasses 25%. This means that a higher percentage of residents in Iowa nursing facilities require less intensive medical care or supervision compared to the average across the entire US and could potentially be served in their community.
According to the National Institute of Health, a 2020 study indicated that 30% of older adults who are hospitalized for an illness and are discharged home have difficulty managing their daily activities, even after the condition that led to the hospitalization is treated. This condition is referred to as hospital-acquired disability (HAD) and puts older adults at risk of rehospitalization.
In Iowa, there is a growing need to support older individuals in transitioning from hospitals or nursing homes back to their communities safely and sustainably to avoid the risk of HAD. Many older adults face challenges such as limited access to support services, financial constraints, and inadequate home modifications, which increase the risk of out-of-home placement and compromise their quality of life. Addressing these challenges through a comprehensive Iowa Return to Community (IRTC) program is essential to enhance the well-being of older Iowans and promote aging in place.
The IRTC program is a short-term, voluntary program serving clients for 90 days or less. It's tailored for individuals discharged from hospitals or nursing home facilities who require services and support to safely stay at home. Using a person-centered approach, the program prioritizes individual desires and needs to ensure a secure return home. If a client needs services beyond 90 days, a Specialist will refer them to Elderbridge’s Case Management Program.
IRTC Goals:
• Support clients in successfully transitioning back into the community from hospital or nursing home facilities by addressing social, environmental, and other barriers that impact health.
• Enhance older adults' safety and independence in the community through services and support.
• Reduce unnecessary hospital admissions, readmissions, ER visits, and facility placements.
• Delay or prevent enrollment in the Medicaid Program.
Outcome 1: Within 90 days, achieve a 70% success rate in supporting clients to successfully transition back into the community from hospital or nursing home facilities. Success is defined by addressing social, environmental, and other barriers that impact health, leading to improved health outcomes and reduced need for institutional care.
Outcome 2: By the end of the 90-day program, 80% of older adults served will report feeling safer and more independent in the community, indicating the effectiveness of the program's services and support.
Outcome 3: Achieve a 50% reduction in unnecessary hospital admissions, readmissions, ER visits, and facility placements among program participants within 90 days, demonstrating the program's impact on reducing healthcare utilization.
Outcome 4: Delay or prevent enrollment in the Medicaid Program for 70% of participants within 90 days, indicating the program's success in maintaining the independence and financial stability of older adults.
Program Eligibility Criteria:
• To be eligible for the program, individuals must meet the following criteria:
• Be an Iowa resident aged 60 or older.
• Reside in Clay, Cerro Gordo, Dickinson, Emmet, Franklin, Hancock, O’Brien, Palo Alto, or Buena Vista County.
• Have an income between 138-300 percent of the federal poverty level (Pre-Medicaid).
• Be on Medicare and/or private pay insurance.
• Express a preference to return to their community and be deemed appropriate for discharge by a doctor following a hospital or nursing home stay.
IRTC Activities:
Referral: Referrals can be made through hospitals or long-term care facilities, and all referrals must meet the program's eligibility criteria.
Pre-Discharge Meeting: A Specialist contacts the client before discharge to introduce the IRTC, confirm client participation, and assess any needs or barriers. If accepted, the Specialist meets with the client at their home upon discharge to complete a care plan.
Service Provider Identification: A Specialist identifies local or regional service providers based on the client's preferences or needs.
Transition Support: A Specialist offers information and assistance throughout the transition, helping secure funding through Medicare, other insurance, private pay, or Elderbridge’s material aid fund.
Home Environment Safety: A Specialist conducts a tour of the home to identify and address safety hazards or concerns.
Follow-up: A Specialist makes phone calls and/or visits the client within 30, 60, 90 days, and at discharge to provide additional support and ensure the client's well-being.
Financial resources are evaluated to determine if the client or their insurance can contribute towards the cost of services or other support. If the client is unable to contribute, the Specialist will use material aid. Material aid provides "wrap-around" funding to help older Iowans remain safe at home longer, or to fill a gap when they return from a hospital or nursing home setting, thereby delaying or reducing the risk of out-of-home placement.
Clients in the IRTC program are (Pre-Medicaid), placing them in the low to moderate-income range. They do not qualify for Medicaid. Most of these clients are on Medicare, which does not cover all unmet needs or services that help older adults return and stay safe in their homes, such as home-delivered meals, a homemaker to assist with laundry and cleaning, or someone to help with bathing, transportation, and other necessities. Additionally, Medicare does not cover the cost of repairs for safety hazards like broken floor tiles or stair railings, or the cost of medical equipment such as a ramp, safety bars, stair lifts, emergency response systems, and more, unless approved by a doctor. However, even then, Medicare often does not cover these needed items. Clients must also meet at least one of the following criteria to receive material aid: the item or service must be medically necessary, maintain safety and/or independence, or delay nursing home/hospital placement. Upon approval, funds are disbursed to a vendor for the item or service.
Bonnie is an example of an older adult who benefitted from the IRTC. She slipped and fell on a broken floor tile in her kitchen, leading to several months in the hospital and skilled nursing care to recover from a fractured hip. Upon acceptance into the IRTC, a Specialist discovered that Bonnie's insurance would not cover floor repairs or a lift for her difficulty with stairs. Bonnie had no additional funds to pay for these items. Elderbridge’s material aid funding covered the cost of floor repairs, a stair lift for access to her bedroom upstairs, and safety bars in her bathroom. Thanks to these interventions, Bonnie has remained safely at home without any hospital readmissions.
Margie, aged 73, was referred to the IRTC after a hospital stay. During cold weather, her furnace failed, and she resorted to using a space heater to prevent her pipes from freezing. However, the space heater was insufficient to warm her home. After paying her monthly bills, Margie had no funds left for repairs. Material aid provided $916.66 to repair her furnace, correcting her unsafe living condition and preventing her pipes from freezing.
As stated previously Elderbridge has several HCBS contracts and meal sites across our region. Many of these providers help us deliver services to IRTC clients. Elderbridge has also established partnerships with several medical facilities for the IRTC program, including Spencer Hospital, Iowa Lakes Regional Hospital, St. Luke Homes and Services Inc, Longhouse/Northshire Care Center, Accura HealthCare, Palo Alto Community Hospital, Hancock County Health System, Franklin General Hospital, and Mercy One. These community partners make referrals and assist in the program's success.
Elderbridge has gradually expanded the IRTC program. Building relationships with hospitals and nursing homes requires time and dedicated staff. There are additional opportunities for presentations and potential partnerships with numerous hospitals and nursing homes within the current 9 counties.
Our timeline or fiscal year runs from July 1 -June 30 each year. Committed funding from IADS helps us to continue with our current counties. Expansion into new counties will be contingent on available funding. If funding is obtained, we plan to extend our reach to an additional one to two counties each year for the next three years. Ultimately, our goal is to offer the IRTC throughout our region. However, at present, we are unable to provide IRTC services outside the 9-county area.
Elderbridge’s existing services align well with the IRTC program and are in line with our agency's mission. The IRTC program meets the needs of older adults aged 60 and above who are pre-Medicaid, medically able, and eager to return home with the necessary services and support. Importantly, there is no other agency in our region that offers an IRTC program, highlighting the unique and valuable role our organization plays in meeting the needs of this specific population.
