By partnering with both upstream and downstream providers, Skilled Nursing Facilities are uniquely positioned to take the lead across the continuum of healthcare to ensure a seamless transition from one level of care to the next. As we see expectations of shorter lengths of stay and patients with higher acuity, coordinated changes will need to be implemented to ensure successful outcomes. One of your goals should be NO surprises at the time of transition.
Hospitals are looking for partners to assist with good outcomes for patients. They need solutions to the problems they are facing as healthcare shifts away from care being provided in silos to more of a continuum of care looking at each episode in its entirety. Hospitals are looking for partners who will help them decrease their readmission rates. Is this something that you are tracking in your facilities, is your therapy department actively working as part of that solution as well? You must be able to provide this information to your hospital referral sources.
You are also seeing a trend for patients who previously have utilized PAC to be discharged directly home from hospitals. One crisis facing Acute Care Hospitals is finding a facility that will accept patients with increased medical needs, they may need to hold on to a patient for several days before adequate placement is found. This roughly translates into a need for Skilled Nursing Facilities admitting more acutely ill patients. If efforts are increased to ensure adequate training of all licensed staff in PAC facilities are focused on increased acuity, this will also place your SNF in a position to be part of the solution.
The time is ripe for therapy and nursing departments to develop niche programming based on specific resident needs. Expanding your model of care delivery and taking the opportunity to integrate multidisciplinary care at the bedside is innovative. Showing good outcomes, decreased LOS, increased patient satisfaction, while reducing readmissions are outcomes that should be highlighted.
Just as hospitals will look to Skilled Nursing Facilities to report their progress and outcomes, the SNFs should be looking downstream at the Home Care Providers and expect the same. Coordinated care across the healthcare continuum is the right thing to do for the patient, be a part of the solution.