Prior focus of transitions of care research was hospital to skilled nursing facility (SNF) and SNF to hospital. With changes in regulations and the creation of bundle payments, readmission penalties, accountable care organization and the expansion of Program of All-Inclusive Care for the Elderly (PACE) and hospice organizations focus has shifted to include emphasis on transitions from SNF to home. PALTC providers can help their patients through these transitions by understanding the local landscape of services available to the elderly. In this session, experienced medical directors from three different states will illustrate the components of effective transitions of care from SNF to home using case studies and describe community resources available to support elderly patients. Speaker will also outline risk benefit framework incorporating clinical judgment and resident’s preference, values and goals.
Describe discharge options appropriate for residents in SNF who continue to require supervision and/or assistance with activities of daily living.
Identify benefits and potential risks associated with each care plan option including remaining in the current location.
Develop discharge care plans that incorporate resident's values, preferences for care and goals balanced with clinical expertise.
Utilize risk benefit frameworks, avoiding safe versus unsafe, and considering “more” safe and "less "safe-as appropriate terminology.