Background: Our healthcare delivery system is serving more than 550000+ patients in Texas and Florida. The SNF (skilled nursing facility) program started in 2008 in San Antonio, TX, and is one of several sub-specialty programs offered thru our organization. Currently there are four physicians and five APCs (advanced practice clinicians) that work in these facilities. Many of the patients in the SNF setting have palliative care needs. In 2019 the supportive care team (SCT) started to collaborate with the SNFs. Due to COVID, the program was on hold. It was reintroduced in October 2022 and has been instrumental for patients with high acuity and with multiple acute and chronic diagnosis.
Objective: The goal of this poster is to describe the referral process, criteria, and collaboration to identify palliative care needs in the SNF setting and the impact of the program.
Description: The SNF team rounds weekly to identify appropriate palliative care patients. Referring criteria include frequent hospitalizations; newly diagnosed cancers; acute on chronic medical conditions, such as heart failure; advanced COPD; functional decline; poor social support; and hospice appropriate patients that have declined hospice. Patients identified have a one-time visit by the SCT to make recommendations and evaluate appropriateness. If approved, further follow-up will be done in the home setting.
Results: Data was obtained using SNF referrals from October 2022 through December 2022. 160 members were admitted to one SNF. Of the 160, 44 were admitted to SCT. From the 44 patients admitted, 20 were admitted into the palliative home visiting program, 8 were admitted to a step-down home program, 10 were involuntary discharged, 4 returned to care of the primary care physician, and 2 were admitted into hospice care.
Conclusion: The PC program in the SNF setting has made a significant impact on our pts healthcare. In the three months of this program, 27% was referred to PCS. These patients will have an extra layer of support upon discharge from the SNF setting to prevent further hospitalization and further identify goals of care.
After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.