Skilled Nursing Facility (SNF) Transition Bundle and 2 more...less...

Skilled Nursing Facility (SNF) Transition Bundle

Skilled Nursing Facilities Transition Service Bundle

Total # of participants enrolled in SNF Transition Bundle

39 enrolleesOct 2018

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Story Behind the Curve

As the provider for this bundle has shifted to working with a "no housing ready" population utilizing a housing first approach, enrollment into the bundle has struggled to meet the target. Other provider challenges include following up on missing items needed to complete referrals into the bundle and few referrals from the SNFs or hospital into the bundles.

Care Connect has performed the following interventions to increase bundle enrollment including:

  • Changed target population from AHS only to AAH SNFs as well
  • Attended monthly case conference at AHS (Fairmont) to promote referrals from SNF
  • Attended Care Management leadership meeting to promote referrals from Acute setting for an upstream approach (prior to going to SNF)
  • Proactively reached out to AAH to increase referrals from members they knew were being discharged to SNF
  • Reviewed work flows and staffing to eliminate bottle necks for intakes (which was leading to missed opportunities for enrollment)

In addition, Care Connect has adjusted the target of this bundle, effective August 2018


Partners include East Bay Innovations, three Alameda Health Systems (AHS) Skilled Nursing Facilities (SNF) units, and Skilled Nursing Facilities sites for Alameda Alliance for Health (AAH)

What Works

Recent partnership with AAH will increase access to these services. In addition, caseload ratio requirements have been lifted to allow for smaller caseloads and more intensive service provision

Action Plan

SNF sites were recently expanded to increase the probability of more referrals to this bundle. Care Connect is currently strategizing to determine how best to support bundle enrollment after pursuing the interventions listed in the Story Behind the Curve. 

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy