Care Coordination: The Next Level in the Post-Acute Network Journey

To improve quality and effectiveness of care throughout the patient’s post-acute care journey, many ACOs are choosing to establish their own network of post-acute partners. High-preforming skilled nursing facilities (SNFs) can contribute greatly to value-based care goals by allowing ACOs to facilitate the implementation of best practices and clinical pathways for delivering care, streamlining transitions of care, and implementing care improvement initiatives. However, once the network is established, “who” and “what” is the driving force behind its success?

This session will explore care coordination strategies that bring post-acute network (PAN) collaboration to the next level. We’ll discuss how ACOs can build trust that results in faster, more confident care decisions made by SNFs who are apprehensive in asking for clinical guidance when needed. Clinical experts will share how to further enhance collaboration with the use of care coordinators dedicated specifically to the post-acute segment and illustrate how live post-acute analytics helps manage this effort. Through first-hand experiences we’ll demonstrate how these dedicated care coordinators will build trusting relationships with SNF clinical teams to deliver effective care transitions, establish standard clinical pathways, monitor high-risk patients, lower length of stays, reduce readmissions, and increase network referral compliance.

Learning Objectives

• Discover how effective care coordination builds trust between ACO care teams and post-acute providers, enabling a true collaborative effort that improves patient outcomes
• Learn strategies to create, implement, and manage a cost-effective, highly trusted care coordination program with post-acute care partners
• Explore best practices on how to leverage post-acute analytics and care coordination to risk stratify and prioritize patients, enhance collaborative care, and reduce rehospitalization risk

Speaker

• Phyllis Wojtusik, RN, Executive Vice President, Real Time Medical Systems

This session is part of the NAACOS 2023 Spring Conference.