Skilled Nursing Facilities
Our Skilled Nursing Facility Medical Services provide onsite care and consultative services with highly trained nurse practitioners as well as remote support from care navigators to partner with the facility’s team and medical director to provide high-quality care 24/7.
The goal is to enhance a healthcare facility’s impact by improving individual-level outcomes and guaranteeing success in any fee for service or value-based environment.
A one-stop-shop medical services delivery team, ready to align with clinical workflows, featuring:
- Nurse-practitioner led, risk stratified, proactive primary care services proven to meet individualized medical and psychiatric medical needs, using associated care paths
- An engaged, interprofessional team of practitioners, medical directors, virtual care-navigators, pharmacy consultants, nursing, and other medical professionals
- A robust focus on a high touch customer interface, elevating nurse competencies using grand-rounding processes, and ongoing learning
- Integrated 24/7 on-call service trained to prevent unnecessary ED visits and hospitalizations
Why This Model Is Unique
This integrated medical support system aligns with facilities’ needs, bringing medical and clinical together, creating a unified care approach, delivering a wholistic wellness model to every resident.
CLINICAL EXCELLENCE PILLARS:
Risk-Stratified Care Paths
Risk-stratified care paths to deliver proactive care (versus a reactive, traditional model).
Care paths place an emphasis on transitional care at admission and at the time of discharge. We focus on communication between acute and post-acute care providers, attention to medication optimization, as well as timely follow-up on laboratory investigations and specialist appointments.
Advanced Care Planning
Advance Care Planning (ACP) provides residents, patients and families the opportunity to discuss their perspectives about goals of care. Care paths include a periodic focus on ACP by practitioners at the time of transitions and as needed to assure patient wishes are honored.
Care paths prioritize periodic medication reviews, appropriate deprescribing and education of patients and families about their medications. Our dashboards track the deprescribing of medications to improve health outcomes, save nursing time, and minimize pharmacologic induced harm.
Chronic Disease Management
Care paths promote proactive follow up visits and an incremental approach to review the status of various chronic comorbidities among patients and residents. It is crucial that the patient and family are comfortably focused on their chronic illnesses to provide input into care planning for these issues. Risk assessments set the frequency of these visits.
Staff And Patient/Family Education
High quality outcomes need staff that are knowledgeable and have the proper skills to care for specific issues among frail patients. We include a focus on regular interdisciplinary grand-rounding processes to improve staff and also engage patients and their families in their own care.
Data Driven Outcome Focus
Data-driven focus on outcomes to promote continuous quality improvement.