Preferred Extended Care Facilities

As part of our coordinated care, the Atrius Health Extended Care Facility (ECF) program has physicians and nurse practitioners located at carefully selected ECFs (Skilled Nursing Facilities and rehab facilities) to provide care to Atrius Health patients. These teams have been successful in returning patients home earlier and reducing hospital readmissions because of:

• Their link to your primary care provider
• Their expertise in managing complex care events, including medication management
• Their involvement at family and team meetings
• The services they bring into the facility, such as a mobile x-ray
• Their close work with both Atrius Health and ECF case management staff in planning for discharge

We strongly recommend that you select one of these select ECF facilities as part of your care plan.  If you select an extended care facility that is not staffed by one of our Atrius Health providers, it will be more difficult to help you with your care.

For many of our patients, including most Medicare beneficiaries, payers allow us when appropriate clinically to admit directly to our preferred ECF facilities without the requirement of a hospital stay first.

Services that our providers offer at a selected ECF can include:

• Admitting new patients to the facility.
• Follow up visit as needed being available to address urgent matter to avoid ED transfer.
• Advance care planning discussion with appropriate documents completed.
• 24 hour/7 day coverage by clinicians who have experience managing patients in the SNF setting and who are able to respond in a timely manner.
• Timely communication to PCP if there is a significant change in the patient’s status.
• Regular participation in team meetings and in family meetings as necessary.
• If specialty care is needed, providers will utilize Atrius Health preferred providers, when clinically appropriate.
• ECF provider will review the patients discharge/follow up needs and ensure that follow up care is appropriate and that the patient is returned to their Atrius Health PCP.
• ECF case managers complete a comprehensive medical review and case management plan for these patients to support patient goals and a safe discharge

The following facilities are staffed by Atrius Health physicians, nurse practitioners, and case managers:

The following facilities are staffed by Atrius Health case managers:

If you have a specific question in reference to a Skilled Nursing Facility, please call (617) 421-6003.