Our Unique Approach to Geriatric Care
THE CARE HUB PROGRAM
Traditional Skilled Nursing Facility (SNF) medical models are reactive and are characterized by frequent missed opportunities for needed care. With the Care Hub program, we are changing all of that.
The Care Hub Program was designed as an interdisciplinary model that focuses first and foremost on the health outcomes of the residents and patients. Based on five key geriatric care elements, the Care Hub team plans proactive visits based on the specific health risk of each resident and patient, as determined by a detailed physical assessment and data review.
Care Hub Components for High Quality Geriatric Care
- Transitional care
- Advance care planning
- Medication appropriateness and de-prescribing to reduce medication burden or harm while improving quality of life
- Chronic disease management
- Staff and patient/family education
Our Outcomes Do the Talking for Us
The successful implementation of care processes requires meaningful accountability. The SHC Medical Partners Care Hub model has comprehensive dashboards and reporting to ensure completion of the care delivery process.
Teams join calls several days a week to review care path compliance and to address any missing care elements. Each practitioner and facility are provided their metrics for care outcomes on demand and at monthly Care Hub operation review meetings.
- Our reports describe key outcomes, such as length of stay, discharge to home or hospital, deprescribing and more.
- The Care Hub team tracks and reports outcomes monthly or on demand.