Evaluation of the Skilled Nursing Facility (SNF) Transitional Care Management Program (TCMP) Using Decision Support on Post-Acute Discharge SNF Length of Stay and Subsequent Hospital Readmissions

Accounting for both significant total medical expense and variation, managing Skilled Nursing Facility (SNF) post-acute care (PAC) utilization has become a major focus area for accountable care organizations (ACOs). In 2017 our healthcare system implemented the SNF TCMP across 5 hospitals for our Medicare ACO population beginning with Hospital D as a pilot in 2015. Our SNF TCMP includes 2 major elements: 1) use of dedicated care managers who oversee the care of our medicare ACO patients requiring PAC SNF level of care through that patient ’s entire PAC SNF episode guided by 2) use of the LiveSafe tool, a proprietary SNF PAC level-of care, decision-support tool to which we purchased access from naviHealth.

Source: Journal of the American Medical Directors Association - February 27, 2019 Category: Health Management Authors: Charles T. Pu, C.T. Pu, Y. Gao, S. Garrels, M. Vestal, M. Turner, C. Vogeli Tags: Research Source Type: research