5 Numbers Illustrating the Medicare Advantage Opportunity in Senior Living

State College, PA – Skilled nursing and rehabilitation communities are an important stepping stone for some people in their preparation to return home after a hospital stay due to illness or surgery. For these patients, their return home may be hampered by medical complications, the need for additional recuperation and therapy services, or the need for additional help in everyday living. Choosing the right skilled nursing and rehabilitation community for recovery is essential.

One of the key success benchmarks for skilled nursing and rehab communities is the percent of short-term stay residents successfully discharged back into the community.

Here in Pennsylvania, one community is experiencing success rates that surpass the state and national averages. Per the Centers for Medicare and Medicaid website, “Nursing Home Compare”, the national average of successful discharge to home is 57% and the Pennsylvania state average is 56.5%. But, in State College, PA, Juniper Village at Brookline is recording a 73.2% success rate. And, Juniper has just celebrated its 100^th resident successful return to home.

Let’s investigate and find out what is making the difference.

At Juniper, discharge planning begins at or even before move-in, oftentimes at the hospital. Juniper’s director of admissions reviews the discharge goal for each referral received and has an in-depth discussion with the hospital discharge planners, the patient, and any family members prior to move-in. Any potential obstacles are communicated and shared with the Juniper interdisciplinary team at the time prior to or at the time of move-in.

Once admitted to Juniper, a comprehensive care plan is developed for each resident that includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment.

For those requiring therapy, Juniper’s therapy department incorporates a strong team approach to developing a plan of care that focuses on the resident’s goals to ensure a safe and successful transition to their highest level of independence.   Therapy works with the resident and caregiver to maximize the functional outcomes by providing simulated real-life situations, for example, homemaking tasks utilizing Juniper’s therapy kitchen and appliances, walks outside, and home evaluations.   “The goal is to instill the optimal level of confidence in their functional abilities,” explains Jessica Paul, DPT.

Also, Juniper starts discharge planning at the time of move-in with the goal of a smooth and safe discharge.  “Our goal is to partner with the resident and family to ensure adequate preparation for a successful discharge. We want the resident and family to have the necessary equipment, supplies, and supports needed to make the return to home a successful experience. It is gratifying to work with resident and family as they move through the rehabilitation process and prepare for return home or their next step,” said Betsy Brett, Licensed Social Worker.

As for medical care, nursing at Juniper Skilled Care works along with an interdisciplinary team to guarantee residents receive the required post-hospital care needed. Once recovery is made so that discharge is possible, nursing ensures the resident has the knowledge and confidence to succeed at home and manage any constant chronic or acute medical conditions, according to Skyler McCoy, RN Wound Nurse/Infection Control.

“Communication among all parties is key to a successful discharge from Juniper back into the community.  Our interdisciplinary team meets weekly to review all skilled nursing and rehabilitation residents.  Participants include the following:  Administrator, Director of Nursing, Director of Therapy Services, Physician Assistant, Social Worker, Registered Nurse Assessment Coordinator, RN Supervisor, Wound Care Nurse, and the Director of Community Relations (Admissions).  All parties provide valuable insight on the goals, abilities, and needs of the individual.  This Person-Centered Care approach ensures the safest and most appropriate disposition,” according to Brenda Dahlberg, Director of Community Relations.

At the time of discharge, residents are provided a final discharge summary which addresses their post-discharge needs. It includes an assessment of the resident’s continuing care needs and a post-discharge plan of care, developed with the participation of the resident and their family. Also, sufficient preparation and orientation is provided to ensure a safe and orderly transfer or discharge from Juniper.

“It’s satisfying to know the work we do helps patients get home and back to doing the things they want to do,” said Victoria Devan, Doctor of Osteopathic Medicine.

Former resident Rodney Brown concurs, “I received excellent care. I would recommend Juniper to anyone. Therapy was top-notch. The CNAs and Nurses were wonderful. I couldn’t say one bad thing.”

Juniper Village at Brookline is an award-winning community in State College, PA, recognized with the Bronze Quality Award by the Pennsylvania Health Care Association; the Best of Senior Living Award from SeniorAdvisor.com; and Excellence in Care, Dementia Care Program of Distinction by the Alzheimer’s Foundation of America (AFA).