Managing Chronic Conditions in SNFs

Skilled nursing facilities (SNFs) face a complex patient and resident population with advanced care needs. While acute illnesses and injuries can present major risks, chronic conditions add another layer to patient complexity.

Chronic conditions are a growing concern in the United States. According to the CDC, an estimated 129 million Americans have at least one chronic disease. In 2020, about 63% of these Americans were between the ages of 60 and 79, and this number is only expected to climb. These conditions can introduce more complications when it comes to care, making proactive management key to reducing these complications, readmissions, and associated costs.

First Docs provides a trusted solution for SNFs and chronic care management (CCM).

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The Role of On-Site Physicians in Chronic Care Management

Chronic conditions require long-term management and a level of oversight that short-term illnesses don’t need. Intermittent physician visits fall short for many patients living with chronic conditions. Between medication requirements and symptom flare-ups, on-site physicians provide more consistent, frequent care than irregular visits with a provider.

Timely, proactive physician care can offer powerful benefits for patient outcomes. For every day a patient waits to see a physician, risk of rehospitalization increases anywhere from 3% to 35%. An on-site physician ensures patients and residents see their providers the moment they transition to your facility, and receive the care they need to manage their conditions.

The challenge is finding physicians who provide the level of time and presence needed for proactive, timely care. At First Docs, our physicians are on-site up to five days a week to offer the level of care needed for chronic care management. With a First Docs physician, your center can deliver immediate intervention and better adhere to treatment plans.

Proactive and Preventive Care Strategies

Early intervention and monitoring are core aspects of CCM for SNFs. Monitoring vital signs and other metrics related to a chronic condition makes it easier for physicians to identify risks. Some studies of chronic care management strategies even showed a reduction in hospital readmissions

Beyond active monitoring, there are a range of best practices for each chronic condition. Common conditions and their care needs include:

  • Diabetes: Blood sugar monitoring is essential for staying within safe ranges and understanding when risks are higher. Combining monitoring and dietary management can help to reduce sugar intake and the potential for blood glucose spikes. High blood sugar can damage nerves and blood vessels in the feet, so regular foot care is also critical for diabetic patients.
  • Heart disease: Patients with heart disease have a higher risk of cardiac arrest. The best preventive care strategy is blood pressure medication and blood pressure monitoring.
  • Dementia: Proactive care strategies for dementia patients include cognitive exercises and structured routines to support mental wellness. Physicians must also monitor behavioral changes to track the progression of the condition. 

A First Docs physician remains informed about best clinical practices for all types of conditions to deliver care for every patient and resident. Best practices like these will be determined on a case-by-case basis. First Docs physicians can also provide support for:

  • Establishing clear CCM processes: CCM needs to be structured in order to be effective. Documenting clear processes makes it easier for your team to collaborate and contribute to shared goals for your patients. 
  • Building collaborative, multidisciplinary teams: Care teams need a wide range of experience to deliver effective, proactive care. Build multidisciplinary teams with skills across the spectrum of care, from physical therapists and specialists to general providers.
  • Prioritizing patients based on risk: Patients enter your facility with a wide range of care requirements. While many of them are recovering from acute illnesses or injuries, chronic conditions can introduce more risks. Assess patients based on their condition to determine how care should be delivered.

The Importance of Patient Education and Family Involvement

While a dedicated, present physician is valuable for managing chronic conditions in skilled nursing facilities, patients and families also need to be involved in these care plans. Chronic conditions have to be managed well after discharge, and education is typically the first step.

Explaining the reasoning behind care plans empowers patients and their families to exercise agency over their care when discharged from your center. A better understanding of the condition can also encourage patients to see a physician when specific symptoms arise. Fostering this proactive approach post-discharge can help to improve care outcomes for the long term and prevent rehospitalizations.

First Docs focuses on patient education as much as presence. Spending more time with patients allows our physicians to understand how each person prefers to learn. With communication that’s tailored for every patient and their families, managing chronic conditions becomes a collaborative effort.

Leveraging Technology for Chronic Care Management

Technology makes chronic care management more accessible. Core technologies to support your SNF include:

  • Electronic health record (EHR) system: Your EHR is the center of a collaborative team. With multiple providers involved in care, it’s essential for everyone to remain informed about a patient’s needs. An EHR makes it easy to update a patient file with current symptoms, care plan changes, and check-up requirements to keep all providers on the same page. 
  • Data analysis: Healthcare data — such as blood pressure over time, dosage changes, and symptom improvement — can provide a comprehensive picture of a patient’s health. With this zoomed-out view, providers can determine the effectiveness of care plans and identify patterns and symptom flares to support more informed care.
  • Telemedicine: A common hurdle for managing chronic conditions is making it to appointments. Telemedicine makes it easier to meet with a physician and supports more effective condition management. First Docs physicians can provide dedicated telehealth services to see patients when they need a doctor most.

Manage Chronic Conditions With a First Docs Physician

Proactive, on-site physicians are key players in managing chronic conditions for your patient and resident population. First Docs provides the physician presence you need with a provider dedicated to timely care, patient education, and technology-driven solutions. Contact First Docs today to strengthen your skilled nursing center.

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