Care coordination for skilled nursing facilities (SNFs) and other health centers is the process of organizing a patient’s care needs with providers and caretakers to ensure those needs are met during and after a stay. Coordinating care post-discharge is especially important for reducing hospitalizations, improving outcomes, and reducing costs.
Care coordination provides notable outcomes for patients in various areas. A study of 9,061 patients in Texas found that the 4,117 patients who received care coordination had a 19% lower probability of hospitalization. In a separate study focused on patient-reported care coordination, patients who received better care coordination according to the 13 HEDIS measures also reported better care outcomes.
Costs are another factor that can’t be ignored in the conversation around care coordination. An evaluation of hospitalizations with care coordination found that patients saved $3,969 in adjusted costs at 30 days. At 90 days, patients saved nearly $6,000.
Your care coordination plan is key to supporting a patient after discharge.
Care coordination must start before discharge to ensure all aspects of care are addressed by the time a patient leaves. The first step in your SNF’s pre-discharge plan is a comprehensive assessment of the patient. These needs may include:
An essential aspect of the pre-discharge stage is collaborating with the interdisciplinary team involved in a patient’s care. Complete this needs assessment with nutritionists, psychotherapists, physical therapists, social workers, and any other key players in the patient’s care plan. Each of these professionals will offer valuable insight.
Once you have determined all the necessary insights and needs, you can document a personalized plan for the patient. This plan should be highly detailed and cover all aspects of care, from medication reconciliation to patient education and upcoming appointments.
Care coordination involves following up with the patient after discharge to ensure the care plan is maintained and to review progress. Your personalized plan will include a series of follow-up appointments where you can check in with your patient.
Each follow-up appointment should include care instructions for upkeep at home. You should also arrange for home health services as needed, whether they’re only required for initial discharge or as an ongoing care plan.
A core aspect of post-discharge is coordinating with caregivers. Your patient may be cared for by a spouse or other family member, and they need to be involved in care initiatives. Oversight from these parties helps your patient commit to care plan items.
You can support your care coordination plan with various techniques to promote the best results for your patients, such as:
Monitoring progress following discharge helps you understand how well a care plan is working and if the approach needs to be modified. When you develop your care coordination plan, establish measurable goals and benchmarks that align with the progress you hope to see from your patient. For example, you might have a goal to lower the dosage of a certain medication by a set date.
Continually review patient outcomes during follow-up appointments and communication channels to get a sense of progress. You can also use surveys to understand a patient’s overall satisfaction with their care plan, which can help you improve care coordination moving forward. The Agency for Healthcare Research and Quality does something similar with the Care Coordination Quality Measure for Primary Care (CCQM-PM).
After review and evaluation, adjust the care plan as needed to improve results.
Care coordination is a valuable part of improving outcomes for patients and reducing their costs. With trusted physicians from First Docs, you gain the leadership and presence you need to implement effective care coordination at your SNF.
Contact us today to learn more.