This symposium will present how post-acute providers can impact the health outcomes of their patients beyond the 30 to 90 days post discharge that they are accountable for managing, The Expanded Chronic Care Model illustrates the importance of the community in improving population health outcomes, but it is unclear how this actually happens. By making these connections, post-acute care providers can further improve outcomes of the populations they are managing long after they transition patients to the community.
The expert panel will discuss the challenges and gaps that occur in the care of complex and frail patients and the common occurrence of their being readmitted within several months of their discharge from the post-acute care setting. These individuals often have unmet social determinant needs and may qualify for extra community supports if they are referred to the appropriate community based organization. They also have issues with low activation as well as challenges in problem solving and behavior change.
The role of Area Agencies on Aging and other organizations to meet these needs through provision of home and community based services, evidence based self-management programs, care transitions programs, and mental health interventions will be discussed.
A checklist of how to proceed in identifying and managing social determinant issues in the community will be provided.
Explain the value proposition of working with community based organizations in improving health outcomes and lowering cost of care for post-acute care populations.
Discuss how the Administration on Community Living has a national work plan to integrate CBOs with healthcare providers.
Use a check list of post discharge challenges (including social determinant needs) and how to approach meeting these identified needs.
Describe evidence based self-management approaches community based organizations can provide to improve the outcomes of rehabilitation populations.
MD, PhD, CMD,
Chief Medical Officer, Continuing Care,