ABOUT US

RN Navigator Team

RN Navigators are registered nurses integrated into the skilled nursing facility care team and extensively trained in a person-centered, proactive, strength-based approach. Our navigators collect and analyze metrics to develop and implement strategies/programs for quality improvement; provide education to increase competence and confidence of dedicated clinical staff; facilitate advance care planning sessions to ensure resident’s values, wishes and preferences are honored; monitor residents for clinical changes in condition; coordinate communication with interdisciplinary care team; perform risk assessments to ensure most accurate plan of care; and serve as a guide/expert for supportive care and the Well-Being Model programs.

Advanced Practice Team

Our Advanced Practice Team partners with PALTC clinical teams to transform long-term care utilizing the Well-Being Model (WBM) Programs. The WBM programs include dementia care, mental health and supportive care. Our clinician’s focus is on improving the quality of life of residents, providing the highest standard of care with an overarching goal of value-based care. We are committed to comprehensive encounters, clinical support, and hands-on assistance with our partners. Effective education to clinicians, clinical staff, and families on principals of residents living with dementia, mental well-being and supportive care allows improved systems, practices and resident outcomes. Interdisciplinary teamwork between the Advanced Practice Team, RN Navigator, LCSW and Quality Consultants streamline comprehensive and resident-centered care.

LCSW Team

Our Licensed Clinical Social Workers (LCSW) are committed to utilizing the highest standards in practice and focused on meeting the mental health needs of all long-term care residents by way of assessing mental well-being, therapeutic conversations, and non-pharmacological interventions. Serving with a proactive, person-centered, strength-based approach to address the mental health needs of LTC residents while providing education to promote culture change regarding mental health. The interdisciplinary team approach between advanced practice partners and LCSWs complement one another’s expertise and dynamically coordinate to work toward shared plans of care, individualized to each resident.

Quality Consultant Team

The Quality Consulting Program focuses on caring for residents in the long-term care setting to improve quality of care and outcomes, improve healthcare experience for residents and reduce unnecessary/preventable hospitalizations. This program also provides long-term care focused education regarding evidence-based management of chronic conditions to prevent unnecessary burdensome, ineffective, or futile diagnostics and treatments. The Quality Consultant Team strives to improve systems, practices, and resident outcomes by ongoing data analysis to construct actionable insights and optimize resident-centered outcomes.