PALTC23 Conference Recordings SA07 Resident Centered Discharge Management: Care Coordination

Resident Centered Discharge Management

“Care Coordination" is a buzzword in post-acute care. This ill-defined word has many definitions for providers, administration, insurance companies, and other care stakeholders, including the resident. As a result, there is little alignment in the goal of coordinating care and thus measurable poor outcomes for the resident. Our goal is to share tools created out of the need to better coordinate care during a resident’s discharge from nursing or therapy services at a skilled nursing facility. Not only can resident’s care be improved when completing a comprehensive review of their current needs, but results have shown the tools can be used as a solution to improve Medicare Part A or managed Medicare length of stay and lower the community readmission rate for a skilled nursing facility.

Learning Objectives:

At the completion of this session, learners will be able to:

  • Apply the tools to residents receiving nursing and therapy services at the skilled nursing facility to coordinate their care.
  • Determine if a resident no longer needs skilled services prior to discharge from the facility.
  • Establish a method for communicating results with the interdisciplinary team.
  • Evaluate the effectiveness of coordinating the resident’s care using length of stay and readmission data.

Jennifer Maina, RAC-CT, PAC-NE, BSN, RN

Jennifer Maina, RAC-CT, PAC-NE, BSN, RN, is a published author and 2019 Rising Star in McKnight’s inaugural Women of Distinction awards with over 25 years of experience in post-acute care. Currently, she is a Vice President of Clinical Excellence and Innovation overseeing the nursing operations of two Continuum Care Retirement Communities.

Madeline Wiger, LNHA

Madeline Wiger, LNHA, is the Executive Director for Oakwood Village's University Woods campus but previously a Quality Assurance Process Improvement Team Leader at Oakwood Lutheran Senior Ministries. She works with the interdisciplinary teams of a Continuum Care Retirement Community campus on daily operations with a focus on regulatory compliance and quality of care. Ms. Wiger is a graduate from the University of Wisconsin - Eau Claire with a bachelor’s degree in Healthcare Administration and a license in the state of Wisconsin as a nursing home administrator.

Sarah Williams-Racette, CCA, CEHRS

Sarah Williams-Racette, CCA, CEHRS, is the Health Information Services Senior Manager and certified medical coder at Oakwood Village Senior Ministries. She has 20 years of experience in long term care health information and diagnosis coding. Ms. Williams-Racette serves as the facility's privacy officer and is their CEHRS, Certified Electronic Health Record Specialist.

Jody Kroneman

Jody Kroneman is a Referral Coordinator with previous experience as a Director of Social Services and membership on the Wisconsin Nursing Home Volunteer Board. Jody holds a bachelor of social work degree from the University of Wisconsin - Whitewater. She currently coordinates post-acute transitions with local area hospitals for two Continuum Care Retirement Communities.

  • 1.0 CME
  • 1.0 CMD Management
  • 1.0 MOC

Release Date: 03/29/2023   |   Expiration: 03/01/2026

Credit Statements:

Accreditation: Post-Acute and Long-Term Care Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. 

CME Designation: Post-Acute and Long-Term Care Medical Association designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CMD Credit Hours: This CME activity has been pre-approved by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) for up to 1.0 management hours toward certification or recertification as a Certified Medical Director (CMD) in post-acute and long-term care medicine. Each physician should claim only those hours of credit actually spent on the activity.

The CMD Program is administered by the ABPLM. Each physician should claim only those credit hours that he/she actually spent in the activity. For further information, contact ABPLM at 410-992-3117 or at cmd@paltmed.org.

ABIM Maintenance of Certification (MOC): Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 Medical Knowledge MOC points and patient safety credit in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.

Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Financial Disclosure Statement:

The Association requires the disclosure of all speaker/faculty/planner’s relevant financial relationships; presence of off-label use of a device or medication; and discussion of any experimental, new or evolving topic prior to each accredited education activity.

If the learner perceives any bias toward a commercial product or service, advocation of unscientific approaches to diagnosis or therapy, or recommendation, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients please report this to the Association's staff.

The following speaker(s) disclosed relevant financial relationship(s): 

  • Julie Gammack, MD, CMD (Planner & Speaker): Stockholder: Amarin
  • Kenya Rivas Velasquez, MD, CMD, FAAFP (Planner & Speaker): OptumRx: Stockholder
  • All other planners, speakers, and AMDA staff have no relationships with ineligible companies.

All relevant financial relationships have been identified and mitigated.

Components visible upon registration.