This document outlines the relationships between hospitals, long-term care facilities, rehabilitation facilities, skilled nursing facilities, assisted living facilities, and other partners involved in post-acute care and patient discharge and transition of care. It identifies the key stakeholders at each facility type including C-suites, directors of nursing, care coordinators, and patients and families. It also lists strategic community partnerships that collaborate on care transitions and key acronyms.

1. Post-Acute Care Relationships:
Patient Post-Discharge & Transition of Care
IPC ELDER
CARE POD
L
LTCFs/NURSING
HOMES
• C-SUITE
• DONs
• C/Cs
• STATIONS
• PATIENTS
• FAMILIES
REHA
REHABS
• C-SUITE
• DONs
• STATIONS
• PATIENTS
• FAMILIES
• CCs
• D/C PLANNERS
SNF
SNFs
• C-SUITE
• DONs
• STATIONS
• PATIENTS
• FAMILIES
• CCs
• D/C PLANNERS
ALFs
• C-SUITE
• DONs
• CCs
• STATIONS
• PATIENTS
• FAMILIES
STRATEGIC PARTNERSHIPS
• HH AGENCIES
• PALLATIVE CARE
• HOSPICES
• PCMHs
• HEALTH HOMES
• COMMUNITY GROUPS
• IDNs
• PUBLIC HEALTH
• MCOs
PHYSICIANS
KEY:
• LTCF: LONG-TERM CARE FACILITY
• SNF: SKILLED NURSING FACILITY
• ALF: ASSISTED LIVING FACILITY
• DON: DIRECTOR OF NURSING
• CC: CARE COORDINATORS
• D/C: DISCHARGE
• HH: HOME HEALTH
• PCMH: PATIENT CENTERED MEDICAL HOME
• IDN: INTEGRATED DELIVERY NETWORK
• MCO: MANAGED CARE ORGANIZATION
• MAKE PRESENTATIONS DURING FAMILY OPEN
HOUSES & QUARTERLY QC MEETINGS