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DHS advisory council urges regional complex‑transitions capacity, data and flexible funding
Summary
An advisory council and DHS staff described efforts to reduce long hospital stays by expanding regional care navigation, data systems, provider training and flexible grants to support timely discharges and community placement.
The House Human Services Finance and Policy Committee heard the Acute Care Transitions Advisory Council report and an update from DHS on a complex transitions pilot that aims to reduce unnecessary long hospital stays and improve discharges to community settings.
DHS said the council’s work centers on building regional capacity to navigate complex discharges, improving statewide data and measurement, and identifying short‑term administrative or funding levers to reduce barriers to timely transitions. DHS described three pilot regions where a complex transitions team is already operating and accepting referrals from hospitals and lead agencies.
DHS staff said referrals typically involve adults with complex medical needs, behavioral health challenges or aggressive behaviors for which local providers lack capacity. The department reported 210 adult referrals and 108 child referrals between November 23 and January 27 during the pilot period and emphasized that current figures are an early snapshot rather than a complete statewide dataset.
The complex transitions team provides a single point of coordination for hospitalized people who are connected to or likely eligible for Medical Assistance. DHS staff described services that the team offers: clinical consultation and training for receiving providers, person‑centered planning, a referral network of providers experienced with complex needs, and limited flexible grant funds to accelerate transitions while MA eligibility or provider billing is established.
Josh Berg, co‑chair of the advisory council, said the council recommends continuing the advisory work or establishing a standing entity to sustain momentum, expanding the regional navigation model, building statewide infrastructure for communication and data sharing, measuring outcomes and disparities, and pursuing short‑term administrative changes and funding to remove immediate barriers.
Council members and DHS staff stressed the need to expand positive‑support practices and workforce training so providers can safely receive complex patients. DHS noted outstanding questions about governance, how many and which regions should be formalized, and what modest, regionally distributed flexible funding would most effectively be used.
Lawmakers asked about how existing funds have been used, the balance between child and adult referrals, the role of the University of Minnesota in training and whether regional higher‑education institutions should be engaged, and where DHS sees the most immediate opportunities for administrative changes. DHS said it contracted with the University of Minnesota Institute on Community Integration to support scaling positive‑support practices and that the agency can share regional RFI or referral summaries when available.
The advisory council recommended both near‑term, low‑cost administrative fixes and longer‑term investments in regional capacity, data infrastructure and provider training. DHS said it will continue piloting the regional approach, collect more complete data and return with additional recommendations and any funding requests as appropriate.
