POST-ACUTE NETWORK APPLICATION

Thank you for your interest in becoming a Preferred or Provisional Post-Acute Partner with Palm Beach Accountable Care Organization (PBACO). Completion of this application allows PBACO to evaluate quality performance, care coordination capabilities, and operational alignment.

FACILITY INFORMATION

Facility Name:

Facility Address:

Billing Address:(if different)

Primary Service Area:(counties served)

Facility Type:(SNF, IRF, LTACH, Home Health, Hospice, Other)

CMS Certification Number (CCN):

Ownership Type:

Number of Licensed Beds:

Dual Certified Beds:

Average Daily Census:

Medicare Certified:YesNo

Medicaid Certified:YesNo

Other payors/contracts accepted:

LEADERSHIP & PBACO CONTACTS

Clinical Leadership Contact:(Name, Title, Email, Phone)

UR/MDS Contract:

Care Coordination / Case Management Contact:(Name, Title, Email, Phone)

Admissions / Referral Contact:(Name, Title, Email, Phone, Weekend Contact)

Executive Leadership Contact:(Administrator/Exec Director – Name, Title, Email, Phone)

CLINICAL STAFFING

Medical Director Name:

Medical Director On-Site Frequency:

Nurse to Patient Ratio (Day):

Nurse to Patient Ratio (Night):

NP / PA Coverage:

Therapy Services Available:(PT, OT, Speech)

Average Therapy Minutes per Patient per Week:

ISNPYesNo

If yes, who:

REFERRAL & UTILIZATION DATA

Number of admissions annually:

Primary referral hospitals:

Top 3 upstream referral hospitals:

Top 3 downstream discharge settings:

Average annual Medicare admissions:

VALUE-BASED CARE PARTICIPATION

Participate in ACO programs:YesNo

Participate in bundled payment programs:YesNo

Participate in Medicare Advantage value-based contracts:YesNo

Other risk-based programs:YesNo

Describe experience with value-based care models:

SIGNATURE

Facility Representative Name:

Title

Name of signee:

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