Among the things that should promote such ties, she lists:
• “Value-based payments are prompting hospitals to work more closely with post-acute providers.
• “Hospitals face Medicare penalties for high readmission rates.
• “Establishing narrow networks of post-acute partners can encourage providers to improve quality of care.
• “Tactics for improving care between acute and post-acute partners include ‘warm handoffs’ that involve actual conversations, not just the exchange of paperwork, between clinicians on both sites.
• “New staffing models, including the use of SNFists {nursing-home specialist worker} and nurse care navigators, are gaining ground.”
She discusses, among other things:
Selection of the right ”first setting”
Standardization across the continuum of care
Longitudinal CARE planning
Nurse care navigators
