Long-term care, nursing homes, and skilled nursing facilities care for residents with increasingly complex medical and behavioral health needs. Many residents live with multiple chronic conditions while receiving care from several providers and specialists. Without effective coordination, this complexity can contribute to fragmented care and gaps in treatment.
Lumina Care works with skilled nursing and long-term care facilities to provide third party care management services, proactive, coordinated care through programs such as Chronic Care Management (CCM), Behavioral Health Integration (BHI), tele-psychiatry, talk therapy, and Transitional Care Management (TCM).
The goal is to help facility care teams coordinate services, develop individualized care plans, address care gaps, and support residents throughout transitions from skilled nursing facilities back into the community.
What Is Care Management in Long-Term Care?
Care management in long-term care involves coordinating services and developing care plans around the specific needs of residents. This can be particularly important for residents who have multiple chronic conditions, behavioral health needs, and several providers involved in their care.
Many skilled nursing facility residents live with chronic conditions such as:
- COPD
- Hypertension
- Congestive heart failure
- Renal disease
And behavioral health conditions, like:
- Anxiety
- Depression
- Alzheimer's disease
- Dementia
- Bipolar disorder
- Schizophrenia
These residents may have multiple specialists involved in their treatment. When several providers are involved without a coordinated approach, care can become fragmented and gaps may develop.
Lumina Care's approach focuses on developing care plans that target specific conditions and establish goals that help everyone involved understand the direction of care.
Why Is Care Coordination Important in Skilled Nursing Facilities?
Care coordination is important because residents in skilled nursing and long-term care facilities may have complex medical and behavioral health needs that require involvement from multiple members of the care team.
Lumina Care describes the challenge as one of alignment: when care plans establish specific goals, everyone involved in a resident's care can better understand what needs to be addressed and work toward the same objectives.
This coordinated approach can involve primary care teams, psychiatric providers, specialists, facility staff, and other members of the resident's care team.
The objective is to move beyond isolated services and create a more collaborative approach to resident care.
Addressing Behavioral Health Needs in Long-Term Care
Behavioral health is another important component of care management in skilled nursing facilities.
Lumina Care identified a need for greater access to psychiatric care among its facility partners. According to Ben Zirman, Senior Vice President at Lumina Care, psychiatric needs among nursing home residents were increasing, particularly around conditions such as depression and anxiety, while the number of available providers was not increasing at the same pace.
Lumina Care addresses these needs through services that include:
- Behavioral Health Integration
- Tele-psychiatry
- Talk therapy
- Care planning
- Coordination between primary care and psychiatric providers
The goal is to bring primary care and behavioral health providers together as part of a coordinated care team.
How Chronic Care Management Supports Nursing Home Residents
Chronic Care Management (CCM) can be used as part of a broader care management strategy for residents with chronic conditions.
Lumina Care works with skilled nursing facilities to identify residents who meet the qualifications for its care programs and develop care plans designed around their needs.
For residents managing multiple chronic conditions, care planning can help identify which conditions and goals should receive attention. Lumina Care describes focusing on two or three specific conditions when developing goals and care plans so the entire care team can remain aligned.
This approach is particularly relevant for residents with complex conditions such as COPD, hypertension, congestive heart failure, and renal disease.
Moving From Reactive to Proactive Care
Staffing challenges and financial constraints can make it difficult for skilled nursing facilities to consistently take a proactive approach to care.
Ben Zirman explains that Lumina Care wanted to help facilities move away from simply reacting to the daily problems that arise in nursing homes and instead take a more proactive approach.
This preventative model focuses on identifying resident needs, creating appropriate care plans, coordinating providers, and making information accessible to facility partners.
Lumina Care describes its model as a preventative care practice supported by data, providers, and operational workflows designed to make information accessible and actionable for facility partners.
Why Active Care Coordination Matters
Technology and reporting can provide valuable information, but Lumina Care emphasizes that care coordination should involve more than simply generating reports.
Ben Zirman explains that Lumina Care wanted to be actively involved in residents' day-to-day care rather than simply sending reports to facility partners and expecting staff to interpret the information independently.
This approach emphasizes active collaboration between care providers and facility teams.
The broader objective is to make sure residents have access to coordinated care and support throughout their care journey.
Supporting Transitions From Skilled Nursing to Home
Care coordination does not necessarily end when a resident leaves a skilled nursing facility.
Lumina Care also provides Transitional Care Management (TCM) for residents who are discharged from a facility and return to a home environment in the community.
During this transition, Lumina Care works to identify and address residents' needs as they move from facility-based care back into the community. Some residents may continue receiving services through programs such as Chronic Care Management and Behavioral Health Integration after returning home.
This creates an opportunity to extend care coordination beyond the walls of the skilled nursing facility.
What Is the Goal of Care Coordination in Long-Term Care?
For Lumina Care, the goal is to provide residents with a more seamless care experience.
That means coordinating with the different teams involved in a resident's care, identifying gaps, developing appropriate goals, and maintaining collaboration as the resident moves between care settings.
As Laura Geiger, DNP, FNP-BC, NEA-BC, Chief Clinical Officer at Lumina Care, explains, the focus is on coordination, collaboration, and working as a team to deliver care to residents.
How Care Management Can Support a More Connected Care Model
Residents in long-term care and skilled nursing facilities may require support for multiple chronic conditions and behavioral health needs at the same time. When several providers and specialists are involved, maintaining alignment can become increasingly important.
A coordinated care management strategy can bring together:
- Chronic Care Management for residents with ongoing chronic conditions
- Behavioral Health Integration for mental and behavioral health needs
- Tele-psychiatry and talk therapy to expand behavioral health services
- Individualized care plans to establish resident-specific goals
- Transitional Care Management to support residents moving from skilled nursing to home
- Care coordination to connect the different teams involved in resident care
Lumina Care's approach combines these services with data and operational workflows intended to help facility partners access information and provide care in a timely and efficient manner.
How Lumina Care Partnered with ThoroughCare to Deliver Care Management
Lumina Care partnered with ThoroughCare to utilize their leading care coordination software platform. Learn more about their successful partnership or download a case study.
Frequently Asked Questions About Care Management in Skilled Nursing Facilities
What is care management in a skilled nursing facility?
Care management in a skilled nursing facility involves coordinating care around the needs of residents, particularly those managing chronic conditions or behavioral health needs. It can include care planning, coordination between providers, and programs such as Chronic Care Management and Behavioral Health Integration.
What chronic conditions are common among residents receiving care management?
Lumina Care identifies COPD, hypertension, congestive heart failure, and renal disease among the chronic conditions affecting many of the residents it serves.
How does behavioral health care fit into long-term care?
Behavioral health can be incorporated into long-term care through services such as Behavioral Health Integration, tele-psychiatry, and talk therapy. Lumina Care describes using these services to help address conditions including anxiety, depression, Alzheimer's disease, dementia, bipolar disorder, and schizophrenia.
Why is care coordination important for residents with multiple conditions?
Residents with multiple chronic and behavioral health conditions may have several specialists involved in their care. Coordinated care plans and shared goals can help the different members of the care team remain aligned.
What is Transitional Care Management?
Transitional Care Management supports residents as they move from one care setting to another. In Lumina Care's model, TCM helps support residents transitioning from a skilled nursing facility back into a home environment and can connect them with continued care management services in the community.
How can technology support care management in long-term care?
Technology can help make clinical information and operational workflows more accessible to facility partners. Lumina Care describes using data, providers, and operational workflows to help facilities access information and provide care in a timely and efficient manner.
Building a More Coordinated Future for Long-Term Care
Care management in skilled nursing and long-term care facilities requires coordination across multiple providers, conditions, and care settings.
Lumina Care's approach focuses on proactive care, individualized care plans, behavioral health integration, chronic care management, and transitional care. By bringing these services together, the organization aims to help facility partners coordinate care and address resident needs throughout the care journey.
For long-term care organizations, the combination of care coordination, preventative care, chronic condition management, behavioral health support, and transitional care represents one approach to creating a more connected experience for residents.
As Lumina Care describes its mission, the focus is on seamless care: coordinating and collaborating with everyone involved so residents receive the support they need as their care needs change.