Nationally Recognized Transitional Rehabilitation Program’s Strategies

Article Summary

Serving patients with special needs, such as traumatic injury or multiple high acuity co-morbidities, is a costly and complex endeavor. Allina Health’s Transitional Rehabilitation Program (TRP) tackled both of these realities head-on—resulting in cost savings while helping this vulnerable patient population achieve a higher quality of life.

Recognizing the need for high-quality data that could prove the TRP’s value to its patients and community, Allina implemented analytics that enabled it to track and report outcomes and costs, demonstrate value, and generate savings for the health system and the community.

The initiative has reaped wide-ranging results in patient improvements and cost savings including saving health systems and communities $3.2 million over a one-year period, 20 percent greater success than traditional skilled nursing facilities in discharging patients to home and community, 20 percent improvement in impairment in brain injury patients (MPAI-4), and 84 percent improvement in spinal cord independence measure (SCIM).


Silhouette of man in a wheelchair raising both arms in joy as he faces the sunrise
Featured Outcomes
  • Saved health systems and community $3.2 million over a one-year period.
  • 20 percent greater success than traditional SNFs in discharging people to home and community.
  • 20 percent overall improvement in impairment in individuals with brain injury. (MPAI-4)
  • 84 percent overall improvement in spinal cord independence measure. (SCIM)
  • 14 percent improvement on patient reported (PROMIS 10) physical health.
  • 13 percent improvement on patient reported (PROMIS 10) mental health.

Disability is one of the most important public health issues in the U.S.; approximately 15 percent of U.S. citizens have disabilities.1 Allina Health believes that people with disabilities and other special needs deserve comprehensive care at every point of the care continuum—including key transition points. Fulfilling that vision is exactly what Allina Health’s Courage Kenny Rehabilitation Institute (CKRI) Transitional Rehabilitation Program (TRP) was designed to do.

Courage Kenny’s TRP can serve as a bridge between acute care and home or community living setting, providing service coordination, skilled rehabilitative care provided by physicians, nurses, and therapists, counseling, life-skills training, vocational training, and social activities. TRP residents have unique needs compared to average nursing home residents; 64 percent have recently experienced a traumatic injury, (such as spinal cord injury, or traumatic brain injury)—90 percent have multiple high acuity comorbidities.

Courage Kenny’s TRP is one of the leading SNF based rehabilitation programs in the country, with Centers of Excellence in spinal cord injury, traumatic brain injury, and stroke rehabilitation. It received a Five-Star Quality Rating for skilled nursing facilities (SNF) in 2015.

“The TRP fills an important niche in the care of patients with disabilities,” says Brian LeLoup, MPT and CKRI TRP Director of Sub-Acute Rehabilitation.


The Minnesota Department of Human Services recognized that CKRI’s TRP required above-the-norm reimbursement for nursing facilities. In 1999, TRP received financial support when legislation passed that allowed a reimbursement adjustment. This legislation was repealed in 2012 by the state as a deficit reduction measure, resulting in an unsustainable financial loss for CKRI’s TRP ($110+ per resident, per day deficit and $1.4 million annual deficit in 2013).

Allina’s TRP needed to become better stewards of resources and prove that it helped people with disabilities achieve their maximum cognitive and physical functionality. It also needed to get new legislation passed that would provide critical reimbursement adjustments. Accomplishing these goals would require a deliberate focus on data and actionable analysis.


CKRI’s TRP implemented an analytics platform from Health Catalyst that monitored the cost of care, tracked patient outcomes, and identified TRP candidates. It created a dashboard that tracked and reported costs,and allowed for useful cost comparisons. The dashboard tracked and reported outcomes in meaningful ways:

  • Patient Reported Outcomes Measurement Information System (PROMIS) on physical independence, mobility, social integration and occupation, and overall mental and physical health score.
  • Health outcomes reported according to nationally recognized clinical evaluation assessments. For brain injury, it used the Mayo-Portland Adaptability Inventory (MPAI) that assists in the clinical evaluation of patients during the post-acute period following a brain injury. For spinal injury, it used the Spinal Cord Independence Measure (SCIM) to measure items related to daily living, coordination, eating, functional mobility, and incontinence.

Using the analytics platform and dashboard, Allina’s TRP proved value to the community. By continuously reviewing patient data, it served those with the biggest need to maximize cost savings.


Reinstated Legislation for Adjusted Reimbursement and Closed Funding Gap

The analytics platform enabled Allina’s TRP to track and report costs and outcomes, demonstrate the value of their services, and generate savings for the health system and community. The TRP successfully lobbied the state of Minnesota to reinstate language specific to TRP to the Medical Assistance Rate Reimbursement policy.

Outcomes Improvements

Saved health systems and community $3.2 million over a one-year period: saved $35,364 per person, per year by improving transition-to-home numbers and reducing healthcare facility utilization.

20 percent greater success than traditional SNFs in discharging people to home and community: 83 percent of TRP residents return to their homes/communities (compared to 63 percent of impairment matched individuals who went to traditional SNFs).

20 percent overall improvement in impairment in individuals with brain injury (MPAI-4): 73 percent of identified TRP patients reached the threshold for significant improvement.

84 percent overall improvement in spinal cord independence measure (SCIM): 88 percent of identified TRP patients met threshold for significant change.

14 percent improvement on patient reported (PROMIS 10) physical health

13 percent improvement on patient reported (PROMIS 10) mental health

“The TRP uses a highly integrated care model with all of the necessary care and support services available to patients … We are very proud of the fact that 83% of TRP patients are able to return to life in the home and their communities.”

 – Brian LeLoup, PT, Director Sub-Acute Rehabilitation, CKRI TRP, Allina Health


CKRI’s TRP will continue using high-quality data to effectively manage services for individuals across the continuum of care and improve outcomes by expanding the TRP care model to include more people with disabilities. Courage Kenny is also working to integrate select program specific practices within the full continuum of its services (including the TRP) to ensure that the person served receives the right care in the right location.


  1. Center for Disease Control and Prevention. (2009). How many people have disabilities?


Health Catalyst is a mission-driven data warehousing and analytics company that helps healthcare organizations of all sizes perform the clinical, financial, and operational reporting and analysis needed for population health and accountable care. Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 50 million patients for organizations ranging from the largest US health system to forward-thinking physician practices.

For more information, visit, and follow us on TwitterLinkedIn, and Facebook.

Care Management Strategy Improves Lives of Stroke Patients

This website stores data such as cookies to enable essential site functionality, as well as marketing, personalization, and analytics. By remaining on this website you indicate your consent. For more information please visit our Privacy Policy.