Post Acute Team Update

SaralinTiedemanBy Saralin Tiedeman, MS, OTR/L, Post-Acute Project Manager


Significant Steps Towards Improving Patient Care, Satisfaction, and Outcomes

For the past year of the DSRIP program, the Post-Acute team has been hard at work.

ffc0c6d3-371f-454f-a88a-0e9e6c651affOrganizing our Post-Acute provider network of over 50 Skilled Nursing Facilities and seven Certified Home Healthcare Agencies and developing plans for implementation of INTERACT protocols have been the priorities.

We have also focused on facilitating the training of management and direct care staff in best practice protocols, and have assisted in the enhancement of Quality Improvement components of our various organizations to accurately review patient transfers. Overall, we have taken significant steps towards improving patient care, satisfaction, and outcomes.

Each organization has worked tirelessly to ensure proper planning, implementation, and roll-out of the INTERACT and INTERACT-like protocols have been completed and monitored.

Administrators, Directors of Nursing, and Management personnel have worked closely with Millennium to ensure each of the prescriptive milestones from New York State are being met and documented correctly. We are making progress, accomplishing milestones together as a network, albeit remaining in our separate silos of care.

Moving forward, we will be concentrating on the continuum of care and the patient’s progression across the healthcare system.

Instead of focusing on each specific setting of patient care, we want to take a step back and analyze how we can make the transitions across the care continuum safe, seamless, and successful for our patients and providers. Facilitating doctor-to- doctor communication; sharing patient records across systems; and developing system-wide best practice protocols are all objectives to reaching the ideal state of unified healthcare delivery we are striving towards.

Taking a look at our policies and procedures for admission and discharge will be our starting block:

  • Do our facilities and agencies have good protocols in place to engage the primary care physician of the patients we are treating?
  • Are our patients effectively connected with their healthcare provider once they leave our care? Are the staff and providers working for our organizations communicating with the patient care team in the community to ensure we are developing a cohesive, achievable discharge plan? (A discharge plan that is taking into account patient factors such as cultural beliefs, health literacy levels, and social determinants of health? One that will not result in a hospitalization, readmission, or ED visit in 30, 60, or even 90 days?)
  • Does our staff have a good understanding of the social supports available in the community to help address some of these concerns, and are they willing to put the time in to connect our patients with these organizations to ensure a safe and proper discharge?

Post-Acute Care is uniquely positioned between Acute care and community-based care, therefore having the most potential patient transitions moving between provider groups. We truly are the bridge between sickness and health for many of our patients. Our ultimate goal is to be certain the care we provide allows them to make it from one side to the other without falling through the cracks.


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