Our Post-Acute Care Continuum Specialists follow-up on SoNE HEALTH attributed patients in our Performance Network Skilled Nursing Facility’s (SNF), including coordinating with the SNF on barriers to discharge planning and communicating with the Primary Care Provider (PCP) and care team regarding the plan of care. Once our SoNE HEALTH patient is discharged from the SNF, the Post-Acute Care Continuum Specialists do 2 Day post discharge phone call to every Accountable Care Organization (ACO) patient focusing on medication review, appointment adherence and symptom review. In addition, they place 14 and 28-day follow-up calls to the patient to ensure the transition back home is going well.
For more information, please contact population health.
