Post-Acute Care

70th AHCA/NCAL Convention and Expo

PAC-6 - Best Practices in Interprofessional Case Management to Optimize Transitions in Care

Speaker(s)

• 

  Jennifer Sidelinker, PT, DPT, GCS

  Vice President, Clinical Services
  Genesis Rehab Services

  Disclosure: Nothing to Disclose
• 

  NovaLeigh Dodge-Krupa, PT, CEEAA

  VP of Integration and Implementation of Practices
  Genesis HealthCare Corp

  Disclosure: Nothing to Disclose
• 

  Dianna Wood, BSW

  Senior Social Service Coordinator
  Genesis Care Transitions

  Disclosure: Nothing to Disclose

To achieve the triple aim of health care—improved patient experience, better health of populations, and reduced per capita cost—effective case management for transitions within and between settings is critical. That requires tight integration of clinical services, patient/family engagement, and continuous coordination among the interprofessional team. This presentation will outline essential elements and illustrate replicable case management best practices that support successful care transitions.

We will detail three best practice standards that our organization implemented: establish an operational interprofessional team; assess risk for rehospitalization and implementing a tailored care plan based on risk profile; and conduct a post-admission patient/family conference within 72 hours of admission.

We will illustrate the importance of case management across care settings through organizational examples, including a skilled nursing/home health partnership best practice demonstration project, and a post-discharge follow-up program involving a team of nurses and social workers for targeted centers.

Learning Objectives:

• Differentiate between an interdisciplinary and interprofessional team, including roles and responsibilities of the most common interprofessional team members and how to leverage these for successful case management.
• Examine best practices for systematically identifying and addressing risk for rehospitalization.
• Demonstrate understanding of resources and information that can be used to establish an effective system for interprofessional case management that supports patient engagement, risk mitigation, and sustainable transitions in care.