Community Transitions: 

Creative Collaborations Move People 

Home

August 4, 2022

Webinar
Welcome

Webinar is hosted by the 

Housing and Services Resource Center (HSRC)

Facilitator

Lori Gerhard, Director, Office of Interagency 

Innovations, Administration for Community Living

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Instructions for Zoom

Audio Options

• Use your computer speakers, OR dial in

using the phone number in your

registration email.

• All participants are muted.

Questions and Comments

• Please actively use chat throughout the

meeting, especially for your comments.

• To ask a presenter a question, please use

the Q&A function.

Or, send your question or comment via email 

to HSRC@ACL.HHS.GOV

This event is being recorded.

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Minnesota Partnership Panel

• Karen Britton, Manager of the Senior LinkAge Line,

Minnesota Board on Aging

• Kathy Vondrum, Senior LinkAge Line Coordinator,

Minnesota Board on Aging, (Prior manager of Return to

Community and Resource Coordinator)

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Slides 6 through 21 are from the Minnesota Board on Aging | www.mnaging.net Minnesota Board on Aging | www.mnaging.net

Integrated Options Counseling and Support 

Karen Britton | Manager | Minnesota Board on Aging

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Overview

The Senior LinkAge Line is a free 

statewide service for older adults and 

their families. In partnership with 

Minnesota’s Area Agencies on Aging, the 

Senior LinkAge Line provides 

information, assistance and connections 

to local services to help people make 

good decisions and remain independent 

in their communities. 

Minnesota Board on Aging | www.mnaging.net 7
Senior LinkAge Line Services 

The Senior LinkAge Line helps older Minnesotans and those providing care statewide.

 It helps Minnesotans plan for their future, stay in their homes, understand housing options 

and find services if life changes. 

 Program: Housing Options Counseling

 It connects people being admitted to a nursing facility with services and to help them live in 

the most integrated setting possible.

 Program: Pre-admission Screening - PAS

 It assists those leaving a facility or hospital to find the services and resources they need to 

return to their homes and communities. 

 Program: Return to Community - RTC

 It navigates Medicare enrollment and supplemental insurance for beneficiaries statewide.

 Program – State Health Insurance Assistance Program - SHIP

Minnesota Board on Aging | www.mnaging.net 8
Senior LinkAge Line Services 

 It educates Minnesotans so they can protect themselves from fraud, waste and scams.

 Program: Senior Medical Patrol - SMP

 It provides assistance to people to help them afford their prescription drugs.

 Program: Prescription Drug Assistance Program - PAP

 It connects Minnesotans with services such as home delivered meals, chore services and 

transportation.

 It connects Minnesotans to financial and legal assistance, as well as advocacy through the 

Office of Ombudsman for Long-term Care.

 It helps people find the answers they need through self-service online tools.

 Program: mnaging.org, seniorlinkageline.com, minnesotahelp.info

Minnesota Board on Aging | www.mnaging.net 9
Senior LinkAge Funding 

State

- Information and Assistance

- Long-Term Care Consultation

- Pre-admission Screening (25%) 

- Prescription Assistance Program

- Return to Community 

Federal

- State Health Insurance Program

- Senior Medical Patrol

- Medicare Improvement for Patients 

& Providers Act 

- Pre-admission screening (75%)

- Supportive services (Title III B)*

*Title III B funding for I & A is at the discretion of the AAA and their needs. 

Minnesota Board on Aging | www.mnaging.net 10
Housing counseling offered to anyone considering a move 

to Assisted Living Facilities 

6,253 Accepted Counseling

5,501 Declined Counseling 

2018

0

500

1000

1500

2000

2500

3000

3500

60 TO 74 75 TO 84 85 + UNDER 60

COUNSELING AGE

Minnesota Board on Aging | www.mnaging.net 11

ACCEPTED DECLINED
Housing counseling offered to anyone considering a 

move to Assisted Living Facilities by Race/Ethnicity

Gender

63% Female

36% Male

0.1% Not collected 

0 1000 2000 3000 4000 5000 6000 7000

2 OR MORE RACES

AMER IND/ALASKAN NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

HISPANIC/LATINO

NATIVE HAWAIIAN/OTHER PACIFIC ...

OTHER RACE

RACE MISSING

WHITE NOT HISPANIC

HWS RACE/ETHNICITY

Minnesota Board on Aging | www.mnaging.net 12

DECLINED ACCEPTED
Pre-Admission Screening 

67,650 PAS in 2018

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

60 TO 74 75 TO 84 85 + UNDER 60

PAS AGE

Minnesota Board on Aging | www.mnaging.net 13
Pre-Admission Screening by Race/Ethnicity

Gender

58% Female

41% Male

.02% Not collected 

.03% Transgender

0 10000 20000 30000 40000 50000 60000

HISPANIC/LATINO

BLACK OR AFRICAN AMERICAN 

ASIAN

AMER IND/ALASKAN NATIVE 2 

OR MORE RACES

NATIVE HAWAIIAN/OTHER PACIFIC ...

WHITE NOT HISPANIC 

RACE MISSING OTHER 

RACE

PAS RACE/ETHNICITY

Minnesota Board on Aging | www.mnaging.net 14
Return to Community 

• To help people live in the least restrictive setting of their

choice

• $8 million is provided annually in state funds

• We help an average 2,000 people a year develop a plan

when leaving a nursing home to remain in their homes

• 10,000 referral calls a year to offer assistance

• Goal for 2022: Supporting caregivers

Minnesota Board on Aging | www.mnaging.net 15
Populations: Return to Community 

Ages of those Contacted

0

100

200

300

400

500

600

700

60 TO 74 75 TO 84 85 + UNDER 60

RTC Age

Minnesota Board on Aging | www.mnaging.net 16
Populations: Return to Community by Race/Ethnicity

Gender

58% Female

42% Male

0 200 400 600 800 1000 1200 1400 1600 1800

WHITE NOT HISPANIC

RACE MISSING

OTHER RACE

HISPANIC/LATINO

BLACK OR AFRICAN AMERICAN 

ASIAN

AMER IND/ALASKAN NATIVE 2 

OR MORE RACES

RTC RACE/ETHNICITY

Minnesota Board on Aging | www.mnaging.net 17
Reasons for Return to Community Referrals

0 100 200 300 400 500 600 700 800 900

OMBUDSMAN REFERRAL

NO LONGER MEETS NURSING FACILITY LEVEL OF CARE 

RESPITE STAY IN NURSING FACILITY

REHAB IS COMPLETE

REGISTERED HWS COUNSELING REFERRAL

UNHAPPY IN CURRENT SETTING

FALSE POSITIVE-READMIT

HOME CARE REFERRAL

CLINIC VISIT

90+ DAY STAY IN NURSING FACILITY

HOSPITAL DISCHARGE

MDS SECTION Q

SELF/FAMILY IDENTIFIED

PREVIOUSLY ASSISTED BY CLS

NURSING FACILITY IDENTIFIED

MDS PROFILE LIST

RTC REASON FOR REFERRAL

Minnesota Board on Aging | www.mnaging.net 18
Senior LinkAge Line Partners - Minnesota AAAs

• Arrowhead Area Agency on Aging (Duluth) Aitkin, Carlton, Cook, Itasca, Koochiching,

Lake, & St. Louis Counties

• Central MN Council on Aging (St. Cloud) Benton, Cass, Chisago, Crow Wing, Isanti,

Kanabec, Mille Lac, Morrison, Pine, Sherburne, Stearns, Todd, Wadena & Wright Counties

• Dancing Sky Area Agency on Aging (Warren) Becker, Clay, Douglas, Grant, Otter Tail,

Pope, Stevens, Traverse, Wilkin Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods,

Polk, Mahnomen, Marshall, Norman, Pennington, Red Lake & Roseau Counties

• Metropolitan Area Agency on Aging (Arden Hills) Anoka, Carver, Dakota, Hennepin,

Ramsey, Scott, & Washington Counties

• Minnesota Chippewa Tribe Area Agency on Aging (Cass Lake) Bois Forte, Grand

Portage, Leech Lake, & White Earth Reservations

• Minnesota River Area Agency on Aging (Mankato) Big Stone, Blue Earth, Brown,

Chippewa, Cottonwood, Faribault, Jackson, Kandiyohi, Lac qui Parle, Le Sueur, Lincoln, Lyon,

Martin, McLeod, Meeker, Murray, Nicollet, Nobles, Pipestone, Redwood, Renville, Rock, Sibley,

Swift, Waseca, Watonwan, & Yellow Medicine Counties

• Southeastern MN Area Agency on Aging (Rochester) Dodge, Fillmore, Freeborn,

Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, & Winona Counties Minnesota Board on Aging | www.mnaging.net 19
Innovation: Looking Forward

Goals

- More self service options

- More ways to interact

- Interact with people how they want – virtual or

in person.

- Identify those with unstable housing options or as

their needs change.

- Develop programs to support caregivers, the isolated

and those with no support network.

- Outreach to underserved populations

- Education of providers on programs that can assist in

transitions.

Minnesota Board on Aging | www.mnaging.net 20
Senior LinkAge Line

Thank you!

7/27/2022 Minnesota Board on Aging | www.mnaging.net 21
Poll: Who Is with Us?

How would you describe your organization’s 

current role in supporting individuals who are 

transitioning to the community?

• Actively support

• Provide occasional support

• Do not currently provide support but may in the

future

• Not applicable

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Poll Results

Chat: What are you and 1 key 

partner currently doing to support 

transitions?

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Iowa Partnership Panel

• Kent Ohms, Community Living Director, Iowa Dept. on

Aging

• Sherrie McDonald, Lifelong Links Director, Connections

AAA

• Robin Shaver, Director of Care Management for

Methodist Jennie Edmundson Hospital

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Iowa Return to 

Community

Care Transition 

Initiative
IRTC Initiative 

Goals

• Help seniors maintain

their independence by

keeping them in their

homes with

wraparound support

services

• Integrate services

through care

coordination and

management
IRTC Initiative 

Goals

Reduce unnecessary 

facility placement, 

unnecessary hospital 

admissions and 

readmissions, and 

emergency department 

use
Key Elements

• Service coordination

at discharge

• Up to 90 days of

intensive services

• Increasing access to

person-centered

planning
Partners 

Current 

Funding Future Direction

• Five out of six AAAs 

participating in IRTC

• Hospitals, SNFs, Clinics • Funding provided by the Iowa General Assembly • Future direction being 

assessed
Panel Discussion

Q&A
ACL Resources for Care Transition Programs

Care Transitions Program Website: 

• Innovative practices from the field

• Care transitions tools

• Care transitions resources

• Care transitions and assistive

technology

https://acl.gov/caretransitions

Questions? Innovations 

to share? 

Send an email to:

caretransitions@acl.hhs.gov

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HSRC 

Website

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acl.gov/HousingAndServices
Upcoming HSRC Webinars

August 22 from 2:00-3:00 pm ET

• Working Together to Empower Community Inclusion: 

Health/Housing/Independent-Living Partnerships

https://bit.ly/3zT11Cm

August 29 from 3:00-4:00 pm ET 

• Continuums of Care and the Aging and Disability 

Networks

All webinar registrants will receive the links to sign up.

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We want to hear from 

you! 

Please email us at hsrc@acl.hhs.gov
Acknowledgment

This presentation was supported in part by the U.S. Administration for 

Community Living through a contract with Mission Analytics Group, Inc. 

(Contract number HHSP233201500060I) which subcontracted the work 

to USAging. The views expressed do not necessarily represent the 

positions or policies of the Administration for Community Living / 

Department of Health and Human Services.