1. FORGING PARTNERSHIPS IN THE CONTINUUM OF CARE
Lorraine Estep, MSW, LSW
Community Liaison to PowerBack Willow Grove and Rydal Park Skilled Nursing

2. Helping the patient navigate the Continuum

3. ASSISTING OUR PATIENT WITH TRANSITIONS

4. Community Liaison Role
Accept Referral for Home Care, Palliative, or Hospice
Review charts
Meet patient; Contact family, Caregivers
Confirm demographics, PCP, D/C plan, educate on Home Care services
Send referral to Central Intake Department
Contact PCP, arrange mobile lab, obtain needed orders, work with SNF transition care team

5. Adjusting involvement to each patient
Minimal Navigation:
- Prepared
- Educated
- No obstacles

6. Complex Navigation:
- Noncompliance
- Significant
obstacles
- Life style
changing event

7. Avoiding disruption to patient’s recovery plan - education - communication - collaboration

8. Outcome: -Patient returns home -care needs are met -patient is successful