Successful Discharge Begins on Admission – Improve Outcomes through Effective Care Navigation and Live Analytics

According to a 2022 JAMA Network study, 1 in 5 Medicare beneficiaries discharged from the hospital receive care in a Skilled Nursing Facility (SNF). With care transitions from one setting to another being a vulnerable space where patients are susceptible to complications that can result in readmission back to the hospital, all stakeholders in the patient journey recognize that care transition interventions are necessary to reduce Emergency Department utilization and improve patient outcomes. Likewise, successful discharge planning, which begins on the day of admission into the SNF, requires the integration of best practices into the care plan that also prevents rehospitalizations.

The key to effective care planning and discharge planning lies in the utilization of post-acute data to inform and guide clinical decision-making while advancing care coordination, ensuring continuity of care and optimal outcomes for patients. This session addresses the importance of a patient-centered, interdisciplinary team (IDT) approach from admission to discharge and beyond. Care Navigation strategies will be shared that showcase how SNF teams, including care managers and social workers who play an integral role in coordinating effective care transitions, can leverage post-acute analytics and Social Determinates of Health (SDoH) indicators to anticipate patient needs and set appropriate, achievable goals throughout the SNF stay and post-discharge. We will demonstrate various methods to facilitate communication of appropriate information during all phases of the post-acute journey among patients, family members, caregivers, nursing staff, acute care providers, and PCPs. Finally, we will explore care management practices, including transition of care standards, that are associated with improved outcomes for patients at high risk for readmission.

Learning Objectives

• Leverage live, post-acute data to help support effective care planning and transitions to provide improved patient outcomes while reducing avoidable hospital readmissions
• Implement best practices and strategies to create care plans that meet regulatory compliance and align with specific Social Determinates of Health and Physical Needs of the patient
• Understand what successful care planning means to provider partners, and how strong collaboration and care coordination efforts can lead to improved Quality of Care and financial outcomes for SNFs

Speaker

• Lindsey Ford, RN, Network Program Manager, Real Time Medical Systems

This live session will be presented at the LifeSpan 2025 Conference.