GeriNet Post Acute — CareConnectMD

Our Post-Acute Care Program

Individuals in post-acute settings deserve only the highest quality medical, administrative and patient care services.

We have talented and experienced physicians, nurse practitioners, and physician assistants who spend 100% of their time practicing in the post-acute care setting.

OUR CARE MODEL

Our unique care model not only improves the experience of patients and residents, but also enhances the quality of post-acute care services delivered, and significantly reduces the cost of that care, offering a brighter future for all. Interventions integrate hands-on care by a Nurse Practitioner and Physician embedded in the nursing home. We help control costs, improve care through decreased ER visits, hospitalization, and ambulance use, and improve patient & family satisfaction.

- Transition patients to the community and communicate with the Health Plan CM and Nursing Home CM/SW.
- Referral to Transitional Care Coordinator based on clinical judgment.
- Collaborative process that coordinates services to meet patients’ health needs and promotes quality & cost-effective outcomes.
- Collaborate with patients, caregivers, and health care teams to coordinate length of stay and transition to appropriate settings.
- Assistance in meeting discharge readiness goals and overall well-being.
- Assessment for post-discharge needs.

- Address end-of-life issues, including hospice and palliative care options.
- Practice awareness of cultural diversity.
- Provide patient education directed at self-care and reduction of exacerbations.
- Coordinate post-discharge services, support programs, and community-based services.
- Participate in interdisciplinary team rounds and weekly meetings with Health Plans.
- Engage with patient or caregiver via telephone or on-site as needed, including attending patient/family conferences.

- Daily support for urgent and non-emergent visits, treatments & follow-up
- Hands-on evaluation, treatment & follow-up for post-acute and long-term residents
- Collaboration & communication with attending physicians, residents & families
- Wound care rounds
- Fall prevention and resident evaluation program
- Urinary incontinence programs
- Discharge readiness monitoring
- GeriNet provides higher-quality patient care
- GeriNet provides much needed continuity of care
- Our post-acute care programs are proven to reduce hospital re-admissions
- Reliable clinical presence focused on shared goals
- GeriNet team supervises and tracks rehabilitation progress, leading to additional reimbursements
- Improved regulatory compliance
- New patients are seen within 24-48 hours of admission to the facility. 24/7 on-call service means quick responses, assessments, and interventions whenever patients require it