Resource Coordination

Just one phone call away – (800) 333-2433.

Every person has the right to live in the setting of their choice. Minnesota Aging Pathways' Resource Coordination service helps older adults remain in their homes or return to their home from a facility or to a new setting in their community by providing free in-depth support and follow-up. Support is also provided to involved family members and caregivers.

Those eligible are:

Have been in a nursing home 90 days or fewer
Want to return home
Would have to stay in the nursing home, if they did not have other help
Are not receiving long-term care services paid for by Medical Assistance (MA)*

How does it work?

A provider (nursing facility, hospital, clinic, etc.) can make a referral or a person can self-refer online.

Once Minnesota Aging Pathways receives a referral, the process usually involves:

Discussing the help that is available
Deciding if participating is right for a person
If so, working together to develop a comprehensive plan that will meet the person’s needs and preferences
- This includes exploring available resources, estimating costs and helping set-up services, such as; home health, meal/grocery delivery, transportation, help around the house, home modification or repair, financial or legal assistance, caregiver support, Medicare and much more.
Follow-up to support long-term success in the community.

Call Minnesota Aging Pathways at (800) 333-2433, Monday-Friday, 8:00 am - 4:30 pm.

*If MA pays for your long-term care, contact your county case manager or health plan care coordinator for help moving out of the nursing home.

MAKE A REFERRAL

Resource Coordination Services

Minnesota Aging Pathways resource coordinators will visit eligible people in nursing homes to discuss whether the person is interested in getting help to move back home.

Working with nursing facility staff, Minnesota Aging Pathways staff will develop a list of services that people can consider having at home to help them after they leave the nursing home. The resource coordinator provides counseling to help people look at all long-term care options based on where and how they want to live.

After a person returns to a community setting, Minnesota Aging Pathways provides follow-up in person and over the phone for up to five years. This ensures that the person remains successful for as long as possible in the home of their choice. The information also will be used to evaluate the service and the effectiveness of ongoing follow-up.

There is no cost for this service.