Perfect Path Case Study

i. Notify the patient’s assigned primary care physician (PCP) that their patient was admitted to your SNF. Upon admission, the Admission Director or Designate will notify resident's PCP to discuss admission to facility and to provide any clinical information needed. ii. Address care directives at the patient’s first visit; During the first 24 hrs of admissions all patients and/or responsible party will be introduced to Pruitt Health's Perfect Path Program. The Perfect Path Program is a transitional program that will help guide the resident's recovery and teaching process from admission to discharge and in the community. Part of the perfect path initiative is a post admission care plan (PAC) meeting within the first 24 hours to
begin discharge planning, patient education and communication from all departments. During this process the Perfect Path team gather all necessary information to help make the resident's stay at the facility successful, fluid and timely. This program will be discussed with the resident and/or responsible party. iii. Schedule a patient’s follow-up appointment prior to discharge with their PCP within 7 days of discharge; Discharge meetings are scheduled with the resident and/or responsible party to determine the continuum of care after discharge and possible discharge date. The discharge team will schedule a follow up appointment with the resident PCP. iv. Provide each patient with a follow-up phone call within 48 hours of discharge (please include whether or not this currently occurs, and how frequently); The Nurse Navigator who is part of the Perfect Path team provides follow-up calls to all residents within 48 hrs per requirement. The Nurse Navigator also encourage the resident or responsible party to contact the DHS or Nurse Navigator with concerns or Change in condition.