Advisory council urges expanded regional capacity and data systems to address patients stuck in hospitals

The House Human Services Finance and Policy Committee received the Acute Care Transitions Advisory Council report and a presentation from the Minnesota Department of Human Services on work to reduce long, avoidable hospital stays for people with complex medical and behavioral needs.

Assistant Commissioner Natasha Merz said the department’s “vision” is that people move through care levels based on clinical need and receive timely, safe transitions back to the community when hospital‑level care is no longer required. She described a DHS complex transitions team that is currently operating in three regions and handling referrals from hospitals and lead agencies.

Josh Berg, co‑chair of the advisory council, summarized the council’s recommendations and stressed the need to continue the council’s work. “The long term vision of this is to be even more proactive and preventative in all of this so that we can keep people where they need to be with the services and supports that meet their needs,” Berg told the committee.

Why it matters

DHS said people with complex medical and behavioral needs sometimes remain in hospitals long after clinical treatment goals are met because the community lacks providers or placement options capable of safely supporting them. Long unnecessary hospital stays can worsen outcomes and drive system costs; the advisory council recommended building regional capacity and a statewide measurement system to identify and address gaps.

Key recommendations and current DHS work

- Continue the advisory body or establish a standing entity to oversee and support further work; the council recommended ongoing stakeholder engagement and greater representation of people with lived experience.

- Expand regional capacity for care navigation: DHS currently operates a complex transitions team in three regions and the council recommended learning from those pilots and scaling a regional model that reflects local needs and resource availability.

- Build statewide infrastructure for communication and data sharing: council members recommended a measurement and evaluation framework to track outcomes, regional disparities and effective interventions.

- Short‑term administrative and grant measures: the council suggested targeted administrative changes, flexible grant funding for regional capacity building and options to reduce barriers (for example, expedited training, funding to support provider readiness and to pay for transition activities while Medicaid billings or authorizations are processed).

DHS overview of current activity

Merz described an operational complex transitions effort. DHS accepts referrals for people who are already on, or likely to be eligible for, Medical Assistance and asks hospitals to wait at least a week before referring the department to allow for routine discharge planning. DHS records and triages referrals and can provide clinical consultation, training for receiving provider staff, person‑centered planning support and limited flexible grant funds to help bridge gaps while billing and authorizations are arranged.

Preliminary data presented

DHS reported that, between Nov. 23 and Jan. 27, the department received roughly 210 referrals for adults (18 and older) and about 108 referrals for children, with aggression or service‑capacity gaps commonly cited as drivers of prolonged hospitalization. DHS emphasized that its current dataset is incomplete statewide and recommended investment in a more comprehensive data infrastructure.

Questions from legislators

Committee members asked about funding for children vs. adults, how existing grant funds are being used, and the extent to which regional higher‑education institutions and local workforce pipelines could help build capacity in Greater Minnesota. DHS said it contracted with the University of Minnesota Institute on Community Integration for targeted capacity building and recommended exploring regional postsecondary partnerships as the program is scaled.

What’s next

The council recommended continued work, additional state and regional resources and establishing a measurement system to identify regional disparities and outcomes. DHS said it will share summaries of RFI‑style outreach and regional pilot results and recommended legislative consideration of modest, flexible regional grant funding to build capacity.