The Post-Acute Care PCMH: A Temporary Home for the Geriatric Patient in Transition from the Hospital

The Post-Acute Care PCMH: A Temporary Home for the Geriatric Patient in Transition from the Hospital

On-Demand Webcast
Speakers

Scott Bolhack, MD, MBA, CMD, CWSP, FACP, FAAP; Amy R. Malkin

ABSTRACT

Creating a medical home for the patient in transition from the hospital often requires stops along the way in rehabilitation facilities and skilled nursing facilities where the involvement of the primary care physician is neglected. In this session, we will review the metrics that we utilize to monitor this system of care; the steps necessary to create a narrow network of professionals and healthcare companies to meet the patients’ goals in the transition of care; and outline the unique qualities of the clinical team necessary to meet the challenges of the patient transferred out of the hospital. We will identify the skills that distinguish this type of program including palliative care, deprescribing, communication avenues with nurses, and how the creation of the Post-Acute Home requires constant education and cooperation.