Post-Acute Care

Overview

The Post-Acute Care (PAC) team coordinates a patient’s care after a hospitalization. For example, they make sure medication and diet changes are on track. Additionally, when patients are dealing with chronic conditions, transitioning from the hospital to a nursing facility can be a challenge, which puts them at risk for being readmitted to the hospital. Our PAC team works hard to prevent this by ensuring patients and their loved ones understand their care plan which can ease the transition to their new stage of care through multi-disciplinary care planning, keeping the patient’s goals at the center of it all.

Care team planning can include:

• Dedicated NPs and MDs
• Pharmacy coordination
• Dietician
• Social worker
• Nurse case manager
• Nursing

A patient's stay is variable depending on their goals; they can expect to see their team on a regular schedule and visits as needed.

During visits the care may include:

• Coordinates care for specialists as needed
• Checks that patients are taking medications appropriately
• Educates them about how nutrition can impact their condition
• Shares information on services they can access (for example, caregiver hours or transportation help)
• Connects them with mental health counseling, as appropriate.
• Patients are generally admitted to PAC on the recommendation of hospital medicine
• physicians. The PAC focuses on serving patients to help them meet their goals.

Services

• Education on chronic conditions
• Medication management
• Provide information on diet and nutrition
• Manage issues involving pain, nausea, and other symptoms
• Make referrals to specialists for additional physical, emotional, and psychological support for patients and their families
• Partner with palliative care and oversee transitions to hospice, as necessary.