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Geriatrics 2018, 3(3), 54;

A Healthcare Pathway to Nirvana? The SNF Transition to Home

Chief Medical Officer, Continuing Care, Lahey Health, Burlington, MA 01803, USA
Received: 16 July 2018 / Revised: 15 August 2018 / Accepted: 22 August 2018 / Published: 24 August 2018
(This article belongs to the Special Issue Geriatric Care Models)
Full-Text   |   PDF [468 KB, uploaded 24 August 2018]   |  


While the majority of attention and the literature has focused on transitional models out of the acute care setting, transitions from the post-acute setting—especially from the skilled nursing facility (SNF)—are not well understood. What are the ‘best practices’, or thoughtful considerations, for a successful transition back to home and the community? Facilitation of a smooth and seamless transition relies on the abilities of the SNF and primary care teams, as well as community agencies, to coordinate care in a patient-centered manner together. This article will focus on this specific transition within the healthcare continuum. View Full-Text
Keywords: transitions of care; skilled nursing; advance care planning transitions of care; skilled nursing; advance care planning

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Saltsman, W.S. A Healthcare Pathway to Nirvana? The SNF Transition to Home. Geriatrics 2018, 3, 54.

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