"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.”
William Gerardi, M.D.
Chief Medical Officer
Home // Post-Hospitalist Staffing // “Post-Hospitalist” Program Goals

“Post-Hospitalist” Program Goals

Enhance and coordinate care of older adults and chronically ill patients in all post-acute settings by utilizing the most cost effective means.

  • Specific Goals
    • Reduce hospital lengths of stay.
    • Reduce the frequency of potentially avoidable hospital (PAH) admissions and readmissions.
    • Reduce unnecessary ER utilization.
    • Improve patient health outcomes.
    • Improve the process of transitioning between inpatient hospitals, post-acute facilities and home settings.
    • Reduce overall health care spending.
  • 45% of hospitalizations among post-acute patients (primarily frail, elderly or disabled) are potentially avoidable.  
    • These hospitalizations are expensive, disruptive, disorienting and often dangerous for this population of patients.
    • These populations of patients are especially vulnerable to the risks that accompany hospitalizations and transitions of care, including transfer trauma, medication errors, hospital-acquired infections and decubitus ulcers.
    • Hospital episodes are even more difficult for individuals with dementia.
    • Six medical conditions are responsible for nearly 80% of the potentially avoidable hospitalizations  (PAH).
      • Pneumonia
      • Congestive Heart Failure
      • Urinary Tract Infections
      • Dehydration
      • Chronic Obstructive Pulmonary Disease
      • Asthma
    • Four behavioral health diagnoses require care coordination and further stratification.
      • 67% of post-acute patients who have a behavioral health (BH) diagnosis are transferred to the ER at least three times per year.  50% of these patients are subsequently admitted to the hospital for further treatment.  The vast majority of these admissions prove to be PAH.
      • There are four behavioral diagnoses that often accompany or may exist separately from the primary medical diagnoses. These diagnoses require stratification in patient care to avoid PAH. These are dementia, delirium, schizophrenia and manic depression.
      • Increased observation, oversight, examination and treatment are required to avoid unnecessary ER transfers and hospitalizations.

Traditional (not Post-Hospitalist/SNFist Programs) Models of Care in Post-Acute Environments

  • Typical community PCPs and most other NP/PA/extender models often do not have the time or ability to effectively monitor patient care when the patient is in a post-acute facility including skilled, intermediate and long-term care nursing and assisted living facilities, resulting in increased ER utilization, hospitalizations and readmissions.
  • When a patient becomes ill with an urgent or non-emergent problem, these other models typically direct the patient to the ER, utilizing the ER as an outpatient clinic, rather than going to the facility the next day and examining and treating the patient on-site.  This results in increased ER utilization, hospitalizations and readmissions.