"The General Medicine clinicians will be supported by the staff of the nursing facilities and our own care coordinators. The ultimate goal of the Integrated Care Program is to improve care coordination via a person-centered, team-oriented delivery system which addresses individual needs.”
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How We Compare
How Traditional Post-Acute Care Facilities Operate:
- Physicians see patients in addition to their regular practice work and hospital rounds, often making as few as one facility visit a month. Patients are seen as infrequently as every two months.
- Facility calls often go unreturned until the end of the physician’s busy day.
- Treatment recommendations and medication changes are often made remotely.
- Inconsistent clinician visits lead to high rates of emergency room visits and hospital readmissions.
- New patients seen within 72 hours, often longer.
- Doctors often not available for care coordination meetings.
- Poor communication between hospital and LTC facilities during transitions leads to missed treatment recommendations, medication changes and follow-up care and appointments.
- Inability to effectively monitor patient rehabilitation leads to missed reimbursements.
- Higher overall health care spending results from higher rates of ER use, hospital readmissions and missed treatment and medication recommendations during transitions.
- Hospitals are scrutinizing which post-acute care facilities they discharge patients to based on their 30-day readmission rates. Facilities with high rates can expect this to negatively impact referrals and their patient census.
- Limited time for doctors to spend with patients.
How General Medicine, Post-Hospitalist Operates within Post-Acute Care Facilities:
- Regular, daily or weekly, on-site office hours provided by physicians who specialize in, and care exclusively for, patients in long-term care settings. Patients can be seen daily if needed.
- 24/7 on-call services mean quick responses, assessments and interventions whenever patient conditions require it.
- Treatment recommendations and medication changes made after on-site assessment are monitored and appropriate follow-up care is given.
- Improved and effective doctor/patient and doctor/staff relationships lead to significant reductions in 30-day and 90-day hospital readmissions.
- New patients seen within 24 hours of admission to facility.
- On-site physicians regularly participate in care-coordination meetings.
- Close communication between on-site physician and discharging facility and physicians means close adherence and monitoring of updated treatment recommendations, changes in medications and follow-up care and appointments improving continuity of care.
- On-site clinicians supervise and track rehabilitation progress leading to additional reimbursements.
- Closer monitoring and regular treatment of patients who are familiar with, and to, their physician builds patient trust and leads to fewer hospital readmissions and E.R. visits. That results in lower overall health care spending.
- Hospitals are scrutinizing which post-acute care facilities they discharge patients to based on their 30-day readmission rates. Facilities with low rates can expect this to increase referrals and positively impact their patient census.
- Physicians have time to spend with patients, consult with other care providers and speak with family members.