This dissertation contributes to the larger policy objective of rebalancing the long-term care system in the United States. Nursing home transition is one of several strategies that states are using in order to reduce long-term care spending, be responsive to consumer preferences and comply with the Olmstead Decision (Kasper and O’Malley, 2006).

Many policy reports have been written about the outcomes and implementation issues associated with transition programs, but little empirical research has been done on the topic. Nursing Home Minimum Data Set (MDS) data are underutilized in nursing home transition efforts and in empirical studies of transition outcomes.

Using the Andersen Behavioral Model of Health Service Use as a framework, this research examines transition outcomes in the context of predisposing, need and enabling characteristics. Enabling variables, which speak to the social and structural context surrounding health care utilization, are more mutable than predisposing and need characteristics and thus are more responsive to policy changes. Therefore, because of their policy relevance, the enabling variables are the focus of this research. Specifically, the following transition-specific enabling variables are the primary variables of interest: community-living preference, presence of a support person who is positive toward discharge, predicted time to discharge and receipt of community living skills training.

Chapter 1 provides a general introduction to long-term care rebalancing, nursing home transition and the Minimum Data Set. Chapter 2 focuses on the theoretical and practical issues surrounding the use of aggregated episodes of care as opposed to unaggregated individual stays in nursing home outcomes research. Chapter 3 outlines the conceptual model, sample and measures that are the basis of the analysis in Chapters 4 and 5. Chapter 4 examines the effect of transition-specific enabling characteristics, insurance and age on community discharge outcomes. Chapter 5 explores the social and structural barriers to transition that prevent residents with a preference to return to the community from doing so. Finally, Chapter 6 provides a discussion of the dissertation as a whole and provides direction for future nursing home transition research.