Post-Acute Care

Working together to prevent patient decline, ensure positive care transitions, and provide quality, evidence-based care to all patients

The Millennium Post-Acute Care Team is working in the Skilled Nursing and Home Care Settings to help lower the rates of hospital readmissions of patients and residents. Together we will be able to achieve 25 percent reduction in avoidable emergency room visits and hospitalizations.

Post-Acute Care image

Facilitating best practices to enhance the patient follow up care after emergency room treatment

Implementing the INTERACT Program & Hospital Homecare Collaborative Solutions Project

The INTERACT Program seeks to decrease rates of hospitalization among Post-Acute patients.

We Are Creating Change…

The Post-Acute Care Team is implementing the following strategies within Skilled Nursing Facilities and Certified Home Health Agencies:

  • Early identification and evaluation of patient symptoms in order to prevent further patient decline and potential hospital admission.
  • “Treat in place” philosophy, caring for patients in house whenever appropriate.
  • Advance care planning and the use of palliative care plans through facilitated end of life conversation with patients, family, and the care team. Generation of meaningful, values-based Advanced Directives and care plans to direct future care decisions.
  • Improve communication and documentation internally within Skilled Nursing Facilities and Home Care Agencies. Utilization of communication protocols and reporting standards to ensure information flow is moving between disciplines in each setting.
  • Improve care coordination and communication across the care continuum, between Acute Care, Skilled Nursing Facilities, Home Care Agencies, and Primary Care.
  • Systematic review and root cause analysis of patient transfers integrated into ongoing Quality Improvement initiatives.
  • Embed in Health Information Technology across care settings, integrate health records into Regional Health Information Organization.
  • Enhance discharge planning across and procedure which is culturally competent, taking into account social determinants of health barriers and patient health literacy. Incorporation of community based organizations and supports to further assist in stabilizing and maintaining good health of patient.

Advanced Care Planning and Palliative Care Committee

The objective of the Advanced Care Planning and Palliative Care Committee is to identify the issues of End-of-Life planning such as patient and provider engagement, and Advanced Directive completion for the patients. Another focus is increasing staff, patient, and family knowledge about End-of-Life issues encouraging conversations to coordinate better care for their loved ones.

Saralin Tiedeman

Saralin Tiedeman, MS, OTR/L
Project Manager – SNF INTERACT
Office: 716.898.6425
Email: stiedeman@millenniumcc.org

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©2016 Millennium Collaborative Care.