Post-Acute Care Relationships:

Patient Post-Discharge & Transition of Care

IPC ELDER CARE POD

L

LTCFs/NURSING HOMES • C-SUITE • DONs • C/Cs • STATIONS • PATIENTS • FAMILIES

REHA

REHABS • C-SUITE • DONs • STATIONS • PATIENTS • FAMILIES • CCs • D/C PLANNERS

SNF SNFs • C-SUITE • DONs • STATIONS • PATIENTS • FAMILIES • CCs • D/C PLANNERS

ALFs

• C-SUITE • DONs • CCs • STATIONS • PATIENTS • FAMILIES

STRATEGIC PARTNERSHIPS • HH AGENCIES • PALLATIVE CARE • HOSPICES • PCMHs • HEALTH HOMES • COMMUNITY GROUPS • IDNs • PUBLIC HEALTH • MCOs

PHYSICIANS KEY: • LTCF: LONG-TERM CARE FACILITY • SNF: SKILLED NURSING FACILITY • ALF: ASSISTED LIVING FACILITY • DON: DIRECTOR OF NURSING • CC: CARE COORDINATORS • D/C: DISCHARGE • HH: HOME HEALTH • PCMH: PATIENT CENTERED MEDICAL HOME • IDN: INTEGRATED DELIVERY NETWORK • MCO: MANAGED CARE ORGANIZATION • MAKE PRESENTATIONS DURING FAMILY OPEN

HOUSES & QUARTERLY QC MEETINGS