Post-Acute Care

Post-Acute Care Program

GeriNet Medical Associates provides physician-led, coordinated medical care for patients recovering from an acute hospitalization in skilled nursing facilities, helping them recover safely, reduce avoidable hospitalizations, and achieve successful transitions of care. We also provide ongoing medical care for long-term residents in nursing facilities, assisted living communities, and board and care homes, specializing in the management of chronic, complex, and high-risk medical conditions.

Our experienced physicians, nurse practitioners, and physician assistants practice exclusively in facility-based settings, delivering hands-on, patient-centered care where it matters most, at the bedside. Through compassionate, individualized care plans and close collaboration with families, facility staff, and other healthcare providers, we honor each patient's goals, preserve dignity, and enhance quality of life throughout every stage of their healthcare journey.

Our care model is designed to provide proactive, coordinated care throughout each patient's stay, with a focus on early intervention, continuity, and collaboration. We partner closely with facility staff, patients, families, specialists, and health plans to anticipate needs, address changes in condition promptly, and support informed clinical decision-making.

• Timely Admissions & Routine Care
  Comprehensive history and physical (H&P) evaluations within 48 hours of admission, followed by routine medical visits and ongoing management for long-term residents.

• Transitional Care Management
  Coordination with hospitals, health plans, case managers, and transitional care teams to ensure seamless transitions across care settings.

• Patient & Family Education
  Education on disease management, medications, self-care, and strategies to help prevent avoidable complications and hospital readmissions.

• Goals of Care
  Advance care planning discussions at admission and ongoing conversations about treatment preferences, including palliative care and hospice when appropriate.

• Discharge Planning
  Collaboration with the interdisciplinary team to estimate length of stay, identify the last covered day, assess post-discharge needs, and connect patients and caregivers with appropriate community resources for a safe transition home or to the next level of care.

• Communication & Collaboration
  Regular communication with patients, families, facility staff, and interdisciplinary teams, including participation in care plan meetings to ensure care remains aligned with each patient's goals and changing clinical needs.

Through this comprehensive approach, we improve coordination, enhance the patient and family experience, support better clinical outcomes, and help reduce unnecessary healthcare utilization.

Services We Provide:

• Daily clinical support for patients

  o   Urgent and non-urgent visits

  o   Treatment and follow-up care

• Hands-on evaluation, treatment and follow-up for post-acute and long-term residents

• Collaboration and communication with patients, families and care teams

• Manage wounds with expert oversight

• Fall prevention and resident evaluation program

• Support urinary incontinence management

• Monitor discharge readiness and coordinate discharge

• Ensure new admissions are seen within 48 hours

Benefits:

• 24/7/365 access to on-call clinical support

• Reduced unnecessary emergency department visits and hospital transfers

• Seamless continuity of care across care settings and transitions

• Evidence-based, cost-effective medical management

• Consistent clinical presence aligned with shared patient care goals

• Enhanced patient and family satisfaction through personalized, coordinated care

• Improved regulatory compliance and quality performance

Comprehensive Care Across Southern California

Supporting residents and care teams at every stage of care.

GeriNet Medical Associates partners with 100+ medical affiliates and healthcare communities throughout Southern California, delivering coordinated medical care where patients and residents live.

SNF / Long-Term Care

Dedicated on-site healthcare services that partner with your care team to enhance resident outcomes, reduce hospital readmissions, and deliver timely clinical support.