IE-SNP is a type of Medicare Advantage Plan designed for patients who live in an assisted living facility. These patients require a skilled nursing level of care but choose to live in a community setting.
A focus on preventative care.
The IE-SNP includes an onsite Nurse Practitioner and RN Care Coordinator to:
- Improve outcomes
- Prevent unnecessary hospitalizations
- Reduce costs
These clinicians assess, diagnose, treat, and coordinate care before health problems become more serious. The clinicians also coordinate all aspects of care with the patient, family, hospital, and physicians, depending on the patient’s needs.
Here again, the IE-SNP is a tech-enabled, value-based care model, designed to mitigate illnesses and prevent unnecessary hospitalizations.
The care team’s roles…
- Completes Annual Health Risk Assessment (HRA) to establish goals and improve health outcomes
- Onsite visits and available on call 24/7 to provide continuity of care
- Coordinates care with the members PCP, facility, and the interdisciplinary care team (ICT)
- Provides chronic disease management, addresses polypharmacy and goals of care
- Identifies, anticipates, and treats acute changes in condition
- Provides education to the facility and all members of the ICT to improve quality of care and outcomes
RN Care Coordinator:
- Rounds on assigned members to identify and escalate member changes in condition to the Primary Care Physician (PCP), Nurse Practitioner and facility to avoid unplanned transfers
- Coordinating integrated care plan development, including collaboration with nursing staff, leadership, as well as the entire ICT according to the Provider Partners Health Plans Model of Care
- Coordination of care needs such as transitions of care, prior authorization and skilling needs
- Assists in development and deployment of education to nursing facility and members
- Ensures members receive all necessary, preventative care and medication reviews to promote wellness and improved outcomes