Abstract
Baylor Scott & White Quality Alliance (BSWQA) created a Transition of Care project in the Post-Acute Care area utilizing embedded RN Care Managers in select North Texas skilled nursing facilities (SNFs) with a goal of reducing length of stay (LOS) in the Medicare Shared Savings Program (MSSP) population. In partnership with the SNFs, RN Care Managers advocated for patients and their families to improve the overall patient care experience with enhanced plans of care and discharge planning to accomplish a decreased LOS resulting in financial savings.
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