In particular, HM groups are increasingly partnering with or hiring “SNFists” to manage the patients they discharge from hospitals. As the name suggests, SNFists are dedicated to treating patients in the SNF environment, just as hospitalists treat patients in the hospital. Nurse practitioners and physician assistants are playing an increasingly important role in this space.
By partnering with SNFists (internal or external to the hospital medicine practice), hospitalists can ensure better continuity of care after discharge and a higher level of care than patients typically receive in a post-acute setting. Often, SNFists are able to detect declines in a patient’s condition early enough to intervene and prevent a hospital readmission. Similarly, their supervision and communication with the hospitalist helps ensure the patient is following the discharge plan and more likely to achieve a prompt recovery.
Leveraging Technology
Though providers across healthcare settings are embracing technology systems such as electronic medical records, most continue to struggle with the lack of system interoperability for adequately sharing patient information.
On a local level, hospitalists can work with post-acute and other partnering providers to help identify what, if any, existing medical record technologies can be made to interface with one another—or if there are any adequate workarounds to facilitate the transfer of patient information and support the continuity of care post-discharge.
Other technology tools, such as telemedicine programs or remote patient monitoring, may also be options hospitalists may want to champion as a way to help manage episodes of care that extend beyond the acute-care hospital stay.
Looking Ahead
There’s no doubt risk-based payment models will continue to gain prevalence in the healthcare market. By thinking beyond the hospital, hospitalists can take a more active role in achieving success in these new models. TH