POST-ACUTE CARE PATIENT MANAGEMENT – the SNFist Program
SNFist program focuses on quality metrics, compassionate and coordinated care, and an improved discharge process.
Designed to address the current concerns:
- Rehospitalization rates 30-days post-discharge
- Reducing Emergency Department (ED) visits
- Decreasing avoidable days in the Acute
High Presence Model in Post-Acute Care: Combating Rehospitalizations through SNF Specific CARE Programs
Our team of Attending Physicians, Medical Directors, Nurse Practitioners, Physician Assistants and after hours Nocturnists works cohesively with facility care teams to prevent and identify complications early, treat and intervene, as necessary.
Patient seen on time < 72 hours (SNF) / 48 hours (sub-acute) by MD & Physician Extenders
Case Management
Tracking and Data for Quality Analysis
Cohesive Medical Management of Patients 24/7
Support for SNF and the clinical providers – Director of Nursing, Pharmacy, and Therapy providers
Documentation & Compliance
24/7 PROVIDER CENTER
Our team of Nocturnists – MD, NP & PAs ensure consistency and round the clock care via telephone management. This aids in creating consistent management of acute changes. The program aims to reduce evening and weekend re-hospitalization by caring for the patient within the SNF environment when possible.
PATIENT DRIVEN PAYMENT MODEL
Designed to assist MDS teams by capturing 122 of the total items set of 3.0 RAI for post-acute facilities. Our team of clinician and certified documentation improvement specialist strive to accurately capture possible case mix indexes (CMI) by live admission review.
PDPM assessment < 48 hours (business)
Quality Improvement: coding specificity, missed opportunities
Tracking and Monthly data Reporting
Education & In-Service
IDT participation
Access to Hospital records