Going home: identifying and overcoming barriers to nursing home discharge.

ABSTRACT

This article describes barriers to nursing home discharge encountered in an intervention designed to transition nursing home residents to the community. Staff in the intervention ("Project Home") provided intensive case management and discharge planning services to nursing home residents who expressed a desire to return to community-based living arrangements. Sixty program participants took part in the program evaluation that informs this article. With the exception of Medicaid status, no differences were found between the social, demographic, and health characteristics of individuals who remained in the nursing home and those who were discharged. A qualitative analysis was conducted to describe barriers to discharge and strategies intervention staff used to leverage each client's strengths and work around obstacles. Three main barriers to discharge were found having an unstable or complex medical condition, lacking family or social support, and being unable to obtain suitable housing. Intervention staff advocated on the behalf of clients, encouraged clients to build skills toward independent living. and contributed extensive knowledge of local resources to advance client goals. Cases of successful transition suggest that a person-centered approach from intervention staff combined with a flexible organizational structure is a promising model for future interventions.