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Patient(s) pathway through Skilled Nursing Care, Works Cited Jones,…

- - - - Care Conference
        
        SNF Discharge
        
        If SNF services are adequate or if insurance runs out, pt to discharge to living arrangement
      - Follow up Care Conference (1-2 weeks post admission) SNF care team involved:
        
        Doctor
        
        RCM
        
        RN's
        
        PT/OT/ST
        
        Social Services
        
        Administration
        
        DNS
        
        Family
      - The Care conference addresses discharge plans & barriers
        
        PT/OT/ST evaluation
        
        Family/Care giver training
        
        Pharmacy review
        
        Transitional living arrangements considered
        
        Return home if home improvements can be made?
        
        Return home with home health services?
        
        Return home on palliative care?
        
        Assisted living facility?
        
        Hospice care?
        
        Should SNF services be extended based off PT/OT/ST eval and insurance coverage?
      - SNF services may be extended, thus prolonging SNF stay.
    - - Emergency/Medical leave
        
        Oregon 3 day bed hold
        
        If pt returns within 72 hours from hospital, SNF services continue, minimally delaying discharge
        
        <72 hr hospital readmission
        
        If pt is discharged from hospital after 72 hours and is still eligible for SNF care, pt readmitted and admission process started over and goals are reassessed
        
        Over 72 hours Rehospitalization
        
        Hospital Discharge