RN Advocates Begin Transition to Home Upon Resident Admission to SNF
In an effort to ensure a smooth transition back to the community setting following a stay in a skilled nursing facility (SNF), Stonegate Senior Living has partnered with Care Navigation Services (CNS) to provide advocacy and education services to its residents. As part of its Care Elevate program, CNS currently staffs a RN Transitional Advocate (RNTA) in several Stonegate SNFs, located in both Texas and Oklahoma (expansion to Colorado is forthcoming). Upon admission to the Stonegate SNF, an RNTA immediately engages residents in their own self-care, utilizing innovative clinical-quality coaching and education strategies. More specifically, RNTAs:
- Identify resident barriers
- Collaborate with interdisciplinary teams to develop resident-centered plans of care
- Provide education regarding disease and treatment plans
- Reconcile medications
- Schedule post-discharge physician appointments
- Provide ongoing support to residents and their families
Additionally, the RNTAs staffed at Stonegate SNFs coordinate residents’ post-discharge care by processing Home Health and Durable Medical Equipment referrals/orders. This ensures that residents have timely access to necessary resources and tools, enabling them to take a more active role in their recovery and ongoing disease management at home.
Stonegate’s commitment to providing on-site RNTAs enhances overall quality of care and the resident experience. By engaging these vulnerable residents in the discharge process upon admission to the SNF, the Stonegate – CNS collaboration focuses on proactively reducing unnecessary returns to an acute care hospital. As a result, residents can confidently recover at home.
