70th AHCA/NCAL Convention and Expo
Multiple methods are employed by the APs that are embedded in the SNF to reduce hospital readmissions. A preferred SNF network and warm hand-offs are used in the transition of care from hospital to SNF. A SNFist is devoted to a given SNF from 8am-5pm weekdays. Designated SNF practitioners provide evening and weekend on-call coverage. Telehealth is utilized in certain SNFs to cover off hours.
New post-acute care admissions are seen within 1 business day. Skilled patients are seen 2-5 times weekly and daily if indicated. APs order same day labs, urinalyses, cultures, imaging studies and EKGs. Resources such as Ask-a-doc, Tigertext, urgent specialty consults and a transfer center are employed. IV antibiotics, IV fluids, IV diuresis, IM medication administrations, respiratory support, and bladder scanning are utilized. Performance of basic procedures, wound suturing, joint injections, I&D are performed within the facility. APs conduct SNF staff education to assist in the complex management of these patients.
APs conduct a formal discharge visit and comprehensive discharge summary including medication reconciliation. The AP provides a hand-off to the community PCP and outpatient care managers to ensure continuity of care. Follow-up PCP appts are scheduled within 7 days of discharge from the SNF.
To capture data we utilize ‘complicated acute visit’, ‘skilled visit’ among others as visit types in the EMR.
During our first month of data in October 2018 we conducted 2936 visits of which 97 visits qualified as complicated acute visits. This visit type suggests the work-up and treatment performed by the AP in the SNF using the methods and strategies described above prevented the patient from going to the ED and/or from being readmitted into the hospital.