Incomplete patient charts. Countless hours spent chasing down patient information. In skilled nursing facilities (SNFs) and other long-term care facilities, fragmented care requires teams to constantly hunt for patient information, leading to frustrated staff and decreased quality of care.
It doesn’t have to be this way. A dedicated medical director can help your SNF overcome care fragmentation and develop a more collaborative culture.
At First Docs, our medical directors go beyond signing forms — they are engaged leaders committed to transforming your SNF into a more patient-centered, collaborative center where all staff are aligned.
Many factors can lead to fragmented care in skilled nursing facilities, from communication challenges to a lack of physician leadership. Common causes include:
Fragmented care has a far-reaching impact, affecting patients, staff, and healthcare organizations as a whole.
Fragmented care means lower quality care. When teams don’t communicate patient information or collaborate effectively, the risk of medication errors, delayed treatments, and hospital readmissions increases.
While fragmented care is a serious issue for any patient or resident, it’s especially dangerous for those with complex health conditions who rely on multiple providers.
For example, one study found that fragmented care for some patients with advanced cancer led to medical errors, unmanaged symptoms, and care delays. It also contributed to dissatisfaction and loss of trust in the healthcare system.
A lack of communication can create a stressful and unsupportive work environment. For instance, nurses and support staff might become stressed as they try to find patient information efficiently — something they would not have to do with a better communication system. They may also become dissatisfied with their work if they have to focus on gathering patient information rather than providing patient care.
Stress, dissatisfaction, and other factors like unclear expectations can contribute to burnout and higher turnover rates.
Fragmented care can be detrimental to your SNF in several ways. First, if care fragmentation leads to decreased quality of care, it can also result in poorer star ratings assigned by the Centers for Medicare and Medicaid Services (CMS). A poor rating can make your facility unattractive to potential residents and their families and cause them to look elsewhere.
Care fragmentation also increases the risk of documentation issues, like incomplete treatment records. This can lead to fines and inefficient use of resources. Staff may order duplicate or unnecessary tests due to poorly coordinated care or lack of communication, wasting time and money. Inaccurate or incomplete documentation can also impact Patient Driven Payment Model (PDPM) requirements, affecting reimbursement.
You can use metrics to identify fragmented care and determine where to focus your care coordination efforts. Metrics can also help you track progress as your center improves and ultimately resolves fragmented care, including:
Addressing fragmented care is necessary to deliver high-quality care, ensure patient and resident satisfaction, and build a positive reputation. Still, since fragmented care often stems from complex issues, successfully resolving it can be challenging. It takes strong, dedicated leadership to truly make a change.
That’s where an experienced medical director comes in. A medical director understands care coordination from a facility-wide perspective. They can uncover the real reasons why teams aren’t connecting. With their insight and leadership skills, they can empower your SNF to finally solve persistent care coordination problems across your clinical teams.
At First Docs, our medical directors go beyond the bare minimum to create collaborative, patient-focused environments where staff feel supported. Our physicians are present up to five days a week, depending on your center’s needs, and actively lead QAPI meetings rather than just check a box for CMS. With their dedicated, on-site presence and proactive, hands-on approach, our medical directors truly get to know and care about staff, patients, and residents. They also come to understand the unique challenges your SNF faces so they can help you overcome them.
First Docs medical directors can solve fragmented care in the following ways and more:
We know you’re driven to achieve your goals, and so are we. Whether you need to resolve fragmented care or hit hospital readmission targets, our medical directors will help you get there.
Here’s some proof. Based on a case study from Bucks County, Pennsylvania, we compared hospital readmission rates between November 2021 and November 2022. In three centers where a First Docs medical director also served as the primary internal medicine attending physician, the 30-day hospital readmission rate was 12% compared to 18.6% in three SNFs where First Docs was not the medical director or attending physician.
The benefits of collaborative care are clear — patient outcomes improve, staff feel more supported and satisfied, and your facility’s finances and reputation grow stronger. In other words, it’s worth resolving issues related to care fragmentation.
Our dedicated medical directors are ready to lead your SNF’s transformation. Contact us today to learn how our medical directors can help your SNF build a more collaborative care model.