For Physicians and Community Providers
Evidence is mounting that efforts to ensure continuity of care for older patients during care transitions can improve patient outcomes. Improved discharge planning and transition processes reduce emergency room visits, reduce hospital readmission rates and reduce overall health care costs. The importance of care transitions to both quality and patient outcomes is recognized by numerous national health care organizations.
Uncoordinated transitions of care all too often result in duplication of services and waste of resources as well as adverse events and avoidable complications. Communication between practitioners in different care settings is frequently deficient and can serve as a potential barrier for a patient’s successful skilled nursing facility discharge.
Services for Primary Care Physicians
PCMA will not assume primary responsibility for your patients however will become an integral partner in their care while at the skilled nursing facility. When discharged from the facility, the patient will return to you for ongoing care management. PCMA will provide the following at the skilled nursing facility:
- Routine presence of physician and/or advanced practice providers in skilled nursing facilities with patients being evaluated upon admission, discharge and routinely throughout their stay and as any issues may arise.
- Board-certified clinicians in internal medicine, family medicine and hospice & palliative care allowing for a customized evaluation and treatment plan for your patient
- Detailed medication and case review by a staffed doctor of pharmacology to minimize polypharmacy and medications errors
- A fully electronic medical record providing a complete discharge summary and accurate medication list in order to improve continuity of care
- Enhanced communication and on-site availability with home health and hospice agencies
- Coordinated discharge planning with case management, social service and patient’s families to ensure a successful community discharge
- Family and caregiver education by our knowledgeable staff
PCMA’s unique services can benefit primary care physicians in several ways:
- Increased patient and family comfort and satisfaction
- Improved clinical and quality of care outcomes, reduced pain and other troubling symptoms, and improved patients’ quality of life
- Reduced diagnostic and treatment interventions, duration of stays, and number of in- hospital deaths while at the skilled nursing facility
- Improved continuity of care and communication leading to decreased readmission rates