Session Summary: This session introduces a disruptive care model: the Cardiorenal Specialist, a clinician trained in both cardiology and nephrology, embedded within the post-acute setting, proactively managing complex medical patients. We will walk through implementation strategies, present case-based evidence, and discuss how this specialist bridges gaps between acute discharge and long-term disease control. By identifying high-risk residents (CHF, CKD, CAD, AFib, AKI) early and initiating on-site diagnostics and therapies, the cardiorenal specialist prevents decompensation and enables facilities to treat in place. Attendees will learn to recognize clinical indicators for cardiorenal referrals and develop a strategy for leveraging this new specialist role to transform quality outcomes.
Learning Objectives:
At the completion of this session, learners will be able to:
Identify clinical triggers for early Cardiorenal Specialist referrals within the SNF setting.
Explain how collaboration between SNF medical directors and embedded cardiorenal specialists can reduce acute care transfers.
Evaluate the outcomes of implementing a Cardiorenal Specialist program on readmission rates, SNF quality measures, GDMT adherence, and disease progression.
