Spotlight on Innovations and Achievements: Connections AAA

Learn how this agency partnered with hospitals, nursing facilities and home and community-based services providers to provide long-term care support planning to assist non-Medicaid eligible individuals to return to community life, maintain independence and reduce hospital admissions.

We're proud to highlight the award-winning work of the 2020 winners of n4a's Aging Innovations and Achievement Awards in this weekly spotlight feature. This week, we are focusing on Connections Area Agency on Aging's Iowa Return to Community program. The agency was a 2020 Aging Achievement Award winner in the Health-LTSS Integration category. The 2020 AIA Awards were made possible thanks to the support of Centene.
The Iowa Department on Aging and Connections Area Agency on Aging (CAAA) have partnered with hospitals, nursing facilities and home and community-based services providers to offer long-term care support planning for individuals who are not eligible for Medicaid. The program helps individuals maintain their independence, prevents early entry into the Medicaid system, and reduces unnecessary facility placement and hospital readmissions. Program coaches assist individuals with accessing transportation to follow-up appointments, obtaining food, understanding discharge and prescription instructions, and more.
In its first year, the program made 595 referrals, with 98 accepted and 74 able to successfully transition back to their homes. One significant outcome came from assisting a client who was age 62 and homeless. He had no health insurance, no income and crippling back pain, which caused him to frequent the emergency room. Less than a year after he started participating in the program, he had health care, income via Social Security and an apartment where he was able to transition to CAAA's case management program.
“The program has created a lot of community partnerships that were not there before. All the providers are more aware of what each other does and how to make referrals to each other,” said Connections AAA CEO Kelly Butts-Elston. “This program has also led to the development of additional collaborative programming, including a Community Interventionist position that receives referrals from first responders, Veterans Affairs, Public Health, among others. The social infrastructure in the county is much more robust because of our care transition program. This benefits the whole community!”
Due to the COVID-19 pandemic, CAAA has completed home visits via phone call or virtually through Zoom. The program coaches have become very adept at being able to ask questions in multiple ways to get the information that they used to be able to see firsthand. The agency also ships durable medical equipment to the home rather than having staff deliver it.
To learn more about the Iowa Return to Community program and how your agency can replicate this program in your community, contact Sherrie McDonald,

For more information about the 2020 winners, see the press release and read the book of winners! To read about past winners and find other best practices for your agency to consider, visit our Best Practices Clearinghouse page.



USAging Fact: Learn about your peers’ work—and how it can fit into your agency’s goals! The AIA Awards recognizes successful and innovative programs that USAging members have developed to serve older adults. Get inspiration from our 2023 winners!