Patients discharged from an inpatient stay to a SNF are enrolled in our care management program. Our dedicated “SNF” team collaborates with the facility team to coordinate patient care. This collaboration includes obtaining weekly progress on family/caregiver support, prior living status, prior level of function, social determinants of health assessment, initial therapy documentation, barriers to discharge, outstanding concerns, and discharge plan.
The goals of this program are to reduce avoidable lengths of stay, ensure care is provided in the right place at the right time, oversee a smooth transition to home, and increase communication back to the Primary Care Provider to decrease gaps in care across the transition.
Services:
- Identify patients admitted to SNF
- Engage SNF regarding plan of care
- Coordinate care while in SNF
- Communicate with PCP as needed (discharge summaries, follow-up appointments, etc.)
- Transitional care at discharge
Population: ACO, Medicare Advantage