Community-based Geriatric Services
About Community-based Geriatrics
We know that planning care for our loved ones and neighbors in assisted living and skilled nursing facilities can be difficult, and often confusing. That’s why at AFM, we have an in-house team dedicated to caring for our patients in several of the assisted living and skilled nursing facilities in our community.
These community-based services allow for:
- Enhanced communication between health care providers, patients, and family
- Reduced travel for office visits
- Coordination of care that encompasses the patient’s medical and emotional needs
- Smoother transitions of care
- Less stress for everyone involved in the patient’s care
Assisted Living Facilities (ALF)
An AFM nurse practitioner, medical assistant, and licensed clinical social worker visit local assisted living facilities in our community weekly.
- Assess acute, medical, and psychosocial care needs
- Follow-up after hospitalization or rehabilitation stay in skilled nursing facility for transitions of care
- Coordinate care and follow up with primary care provider and specialists
- Work closely with patients and their families to create a medical plan of care that encompasses both medical and emotional needs
- Assess the safety of patients’ living situations; assist patients and families with transition into higher levels of care when needed
- Assess patients who have physical limitations or memory deficits that limit travel to clinic, and communicate with family to discuss findings and changes in patient’s plan of care
- Discuss advance care planning including MOST forms, living will, and POA documentation
- Conduct home visits for homebound/hospice patients as needed
- Collaborate with the staff geriatrician for complex geriatric patients
- Provide routine weekly & monthly visits to patients – including Coumadin management and INR checks
In addition to the services our staff provides on site, we also have a provider on call for the needs of our patients in the assisted living facility community.
Skilled Nursing Facilities (SNF)
An AFM nurse practitioner, nurse, licensed clinical social worker, and several physicians see long-term care and rehab patients in Skilled Nursing Facilities in our community.
- Enhanced communication with patient’s primary care provider while they’re in the facility
- Assisting with transitions of care in all settings – including hospitals, rehab, long-term care, as well as assisted and independent living
- Providing routine weekly and monthly visits to patients in rehab, skilled nursing, and memory care units – including Coumadin management and INR checks
- Coordinating services with community resources or specialists
- Communicating with families regularly about their loved one’s status and updates
- Coordinating assistance with our licensed clinical social worker for complex levels of care, advanced care planning, and transitions of care when needed
Just as with the ALF team, our SNF team is on call for the needs of our patients in the skilled nursing facility community to ensure continuity of care.