The transition of older adults from the skilled nursing facility (SNF) setting back to the community has been largely understudied or not explored in the transitions of care arena. We will use this session to explore and expand upon optimizing best practices for patient centered, trans-disciplinary, seamlessly coordinated care among provider and community-based teams working to transition their often medically complex and physiological frail patients, from the SNF, back to "home".
Discuss strategies to help providers coordinate care and utilize community and home-based resources to facilitate and improve the transition of complex older adults from the SNF setting to home.
Identify the unique challenges of care transitions from the SNF to the home environment, and how these strategies can be utilized to support family, caregivers, and the community-based, health care team to maintain wellness and reduce the risk of hospital readmission, appreciate the evolution of the advanced practitioner’s (AP) function in the team management and care of the skilled nursing patient.
Investigate opportunities to maximize the AP role for the patient, as well as families and caregivers, transitioning from the SNF setting, focusing on safety and quality improvement practices.
Explore options and techniques in managing the highest risk segment of older adults, especially those with dementia or life-determining illnesses, in order to maintain their safety, comfort, dignity, independence, and quality of life as they transition to home.
Review, incorporate, and operationalize best practices for creating a seamless transition back to the community that facilitates coordination of care, medication reconciliation, and implementation of an understandable care plan by the SNF and the expanded, community-based, health care team.