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Patient Navigator Program - Increases Referrals and Decreases Readmissions.

December 6, 2016

 

Boardwalk Homecare, the leader in home care services for New Jersey, is excited to announce the launch of its Patient Navigator Program
 

In the wake of the Hospital Readmissions Reduction Program (HRPP), our unique program has been designed to drive collaboration among home care providers, skilled nursing facilities and hospital systems with a key focus on improving patient outcomes. 
 

About the Program 
The Patient Navigator Program acts as a bridge to help families connect with the right level of care as they transition from hospitals to rehabs and then eventually back to their home. The program uses a combination of tasked personnel as well as intuitive software and procedures to improve patient monitoring within the first 30 days of being discharged from a hospital and beyond. 
 

Patient education is a key driver of the program. Boardwalk Homecare's case management team spends a considerable amount of time helping families understand and navigate various home care options prior to discharge. Additionally, families are assisted in developing an action plan prior to returning home to help with the transition, service expectations and patient supervision. 

Once Boardwalk Homecare patients are set up with services, they are quickly introduced to our team of professionals who will take on an active role in orientating and monitoring the patient’s health, needs and progress. The Patient Navigator Program has triggers in place to identify possible complications and remedy them in an efficient manner with the support of our case management team. 


Boardwalk Homecare’s program also aims at keeping open lines of communication in relation to patients, caregivers, family members, healthcare practitioners and skilled nursing facilities. It is our belief that a patient’s home care success is highly determined by a motivated team of individuals who share a common goal and are willing to work closely together for the welfare of the patient. 
 

The Benefits 

Social Work: Case Managers at Boardwalk Homecare are committed to helping improve the discharge readiness of patients requiring higher levels of care. Our team of case managers are available to meet with patients and their families in advance to fully comprehend circumstances, care requirements, concerns and priorities. As experts, our Case Managers will present all available home care options, preparations and best practices needed to maintain a safe discharge home. 

Administration: Boardwalk Homecare’s team of Registered Nurses and Case Managers will use internal systems to create and closely monitor patient progress and records throughout the first 30 days from a hospital discharge. Our Certified Home Health Aides are also trained to detect and report any change or decline in a patient’s health using the Stop and Watch – Early Warning Tool. All 30 day reports will be sent to the appropriate facility for their own records. If a patient’s health noticeably declines, Boardwalk Homecare will also look to coordinate with healthcare practitioners to determine the best option for avoiding a trip back to the hospital – one choice may include coordinating a readmission to the SNF. 

Admissions: Boardwalk Homecare will continue to document all patient hospitalizations beyond the current 30 day period set by the CMS. In addition, our case management team has been authorized to notify the appropriate SNF about any of their former patient’s recent hospitalization. This new level of proactive communication will assist SNFs in potentially pre-booking former rehab patients back into their facility to drive a higher level of continuity and quality of care. 

Ready for Results? 
Boardwalk Homecare’s Patient Navigator Program promotes patient-centered collaborative care and we believe it will prove useful to SNFs looking to improve the outcomes of discharged patients, advance their level of trust with partnering hospitals and to generate home care referrals. 
 

Over the past 3 years of internally tracking 30 day discharge dates (from SNFs...which goes well beyond hospital discharge dates) and the hospitalizations of Boardwalk Homecare patients, the implementation of our unique program has resulted in ZERO hospital readmissions as per the criteria outlined by CMS. Due to the incredible success internally, Boardwalk Homecare has engineered the Patient Navigator Program so that external SNFs can also experience its success. 
 

If your team is seeking better results with a home care company and would like to pilot the Patient Navigator Program, please feel free to contact Boardwalk Homecare. 

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