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Expanding Long-term Care Choices for the Elderly

Diversion & Relocation Strategies


Penny Black, Director, Home and Community Based Services Division, Washington Aging and Adult Services Administration, Olympia, WA.

Dorothy Ginsberg, Project Specialist, Division of Consumer Support, Community Choice Initiative, New Jersey Department of Health and Senior Services, Trenton, NJ.


Washington State began efforts to relocate people from nursing facilities (NFs) to the community in 1991 and aggressively implemented a concerted effort in 1995. Priorities for the Nursing Facility Case Management program are newly admitted Medicaid NF residents, Medicaid applicants who will be eligible within 180 days, and persons who are dually eligible for Medicaid and Medicare. All of the State's six regions have annual Medicaid caseload reduction targets; the State compiles monthly statistics to study trends and see if targets are likely to be met.

Case managers are assigned to specific NFs and do not have responsibilities beyond assessing and working with clients to be relocated. A case manager visits the new resident within 7 working days of arrival to assess the resident's functional and income eligibility. Washington developed the Comprehensive Adult Assessment tool, which is used for assessing people age 18 and over to determine eligibility for all residential settings. The case manager reviews the individual's records and interviews him/her, family members, and NF staff. The case manager then determines whether the resident is an active relocation client or a maintenance client.

For active relocation clients, the case manager determines the actions that need to be taken and the people who need to be involved. Talks with the resident about community-based options and preferences begin within 2 weeks; this allows some time to pass after the crisis that resulted in the individual's entrance to an NF, yet starts the process before an interested person can begin to functionally deteriorate. Ms. Black noted that determining what constitutes "discharge potential" has required retraining of case managers to "think outside the box."

For maintenance clients, the case manager determines an ongoing monitoring plan.

Funds from the Civil Penalty Fund (financed through fines for NF violations) are used to pay for security deposits, utilities, furniture, home modifications, and other housing costs. Case managers have flexibility in the use of these funds.

Many of the people relocated from NFs are disabled and under age 65. Of those discharged from NFs, approximately 58 percent moved home; 49 percent of these people receive no services. Twenty-four percent live in community residences. Assisted living facilities (ALFs) are usually not a relocation option, as people's needs are too great.

Washington also tried a hospital diversion program, but it was unsuccessful. Potential clients were simply too sick and in crisis to make choices.

New Jersey

New Jersey developed the Community Choice Initiative from another process already in place; it was officially implemented in 1998. It has four facets:

  1. Counseling provided by specially trained social workers and nurses.
  2. Transition assistance to facilitate the move from the NF to the community.
  3. Resources for all providers, clients, family members, and others.
  4. Collaboration with Area Agencies on Aging, county Boards of Social Services, and the Office of Long-term Care Options.

Community Choice has 40 counselors in all of the State's 21 counties. Counselors complete the following:

  • Identifying appropriate clients: Initial client contact comes through hospitals, self-referral, family members, and NFs. Initial screenings are done within 5 working days. A range of people are considered appropriate, including people with higher acuity and with cognitive impairments.
  • Evaluating the care needs: This involves collecting information from multiple sources, including the State-developed Comprehensive Assessment Tool, Minimum Data Set, hospital and NF records, care plans, interviews with clients/family members/discharge planners, quarterly care meetings, and family conferences. Ms. Ginsberg noted that, in addition to client preferences, family caregiver concerns are taken very seriously.
  • Determining resource availability: Counselors next determine the availability of community resources that accept Medicaid. Clients are not often placed in ALFs; most go home or into a home setting.
  • Facilitating the transition process: This involves establishing working relationships with community providers, becoming a resource for discharge planners, working with families, and assisting transitions with funds available for security deposits and household necessities.
  • Following up after discharge: Each client is contacted within 48 hours of leaving the NF by telephone; the caregiver is contacted instead if the client is cognitively impaired. If the counselor has any concerns, he/she will make a home visit. If everything is going smoothly, the next followup contacts are conducted at 14 and 28 days. Some clients are case managed; those who do not need active case management are educated on how to access additional services and benefits.

Ms. Ginsberg noted that they have been very fortunate in obtaining funds for Community Choice. In 1999, the Governor committed funds to senior initiatives for 3 years. These funds have been used to expand staff and available services. The State also received a grant from the Health Care Financing Administration (HCFA) Home Transition Grant Initiative, which has allowed program planners to concentrate on areas such as quality assurance (including the development of a policies and procedures manual), barriers, education to NF providers, and marketing information for consumers (including a brochure and information on the State's Web site).

The issue of safety, particularly in homes in rural areas, was discussed. In response to a fire in a boarding home several years ago, the Federal Government required residential programs to retrofit and develop evaluation plans within certain time limits; the State will not pay for people to live in residences unless they have adequate staff to ensure evacuation. The Federal Government has also made it a priority to license new homes in rural areas. New Jersey has developed resources and pilot projects in rural areas to create safer options.


Other workshop participants offered their States' experiences with deinstitutionalization programs. In particular, Colorado has had success with its 3-year-old "bounty" program. The State pays Single Entry Point agencies to identify NF residents who want and have the functional potential to move into the community. The bounty fee is $200 per assessment, and $450-500 if the client moves into the community. In the program's first year, the State saved $347,000 by moving 68 people from NFs into the community. Most of the 250 people served through this program have moved to ALFs.


Community Choice. Brochure. Trenton (NJ): The Choice, Department of Health and Senior Services, Division of Consumer Support, Office of Long-term Care Options; 1998 Aug.

Community Choice. Flyer. Trenton (NJ): The Choice, Department of Health and Senior Services, Division of Consumer Support, Office of Long-term Care Options; 1998 Aug.

Community Choice Initiative. Background paper. Trenton (NJ): The Choice, Department of Health and Senior Services, Division of Consumer Support, Office of Long-term Care Options; 1998 Aug.

Rutgers State Health. Rutgers News. New Brunswick (NJ): The State, Office of Media Relations and Communications; 2000 Apr.

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