Post-Acute Care is an end-to-end post-acute offering that manages up to 90-day episodes of care, beginning prior to the patient’s discharge from the hospital, or for elective surgical cases, outreach begins prior to hospitalization. The program identifies the likely best site-of-care for the patient upon hospital discharge, manages length of stay (LOS) if a Long Term Acute Hospital (LTACH), Skilled Nursing Facility (SNF), Institutional Rehab Facility (IRF) is appropriate, and reduce hospital readmissions. Our program also coordinates the services required for a patient to transition to their home
The Nurse Liaison is an in-market position responsible for identifying and influencing the best site-of-care for the patient upon hospital discharge and manages length of stay (LOS) for Long Term Acute Hospital (LTACH), Skilled Nursing Facility (SNF), and Institutional Rehab Facility (IRF) for their assigned acute and post-acute care facilities. The Nurse Liaison will collaborate with facility discharge planners, patient and family to develop a discharge path of care. The Nurse Liaison will participate in Care plan meetings and meet with patients as appropriate.
Supports the following additional duties as requested: