Projects / SNF Coordination Prototype

SNF Coordination Prototype

From clinical notes to a
coordinated SNF admission.

A fictional workflow prototype showing how reviewed clinical information can populate admission forms and guide the handoffs between referring teams and an accepting skilled nursing facility.

Open the fictional SNF prototype Discuss a walkthrough

Video walkthrough

Direct PCP-to-SNF admission

Watch the referral workflow, then explore the fictional prototype below.

Watch on YouTube

What the prototype demonstrates

Review the facts.
Reuse the work.

One source can support a clinical review, a form and a handoff. Each use keeps its evidence and responsible reviewer visible.

  1. Source documentation

    Inspect fictional PCP, ED, PT, care-management and nursing records.

    Patient · author · date · origin

  2. Reviewed facts

    Accept supported information once. Keep missing or conflicting facts visible.

    Evidence stays inspectable

  3. Populated forms

    Reuse reviewed information in the official Florida 3008 and PASRR drafts.

    Review and signatures stay separate

  4. Accountable handoff

    Follow the next action through authorization preparation, departure and SNF receipt.

    A named role for each step

Workflow illustration. Open the prototype to inspect the actual source records, official blank forms and populated fictional drafts.

The problem

Direct admission to a skilled nursing facility (SNF) brings together clinical documentation, patient agreement, facility acceptance, authorization, screening, medications and transportation. When responsibilities and missing information are unclear, teams spend time searching, re-entering information and arranging follow-up.

What I built

I translated PCP and ED care-transition experience into a working prototype, directed its development with AI, and tested the resulting workflow. The application reuses reviewed fictional facts to populate forms, identifies unresolved requirements and keeps professional decisions separate from administrative preparation.

The 3008 and Preadmission Screening and Resident Review (PASRR) forms are populated through deterministic code. The displayed AI proposals are scripted examples, and the EHR and Florida HIE/CRISP import routes are simulated. No live system or organization is connected.

Where automation helps

Less repeated entry.
A clearer next step.

Reviewed information carries into forms and packet records. The user can focus on missing facts, clinical interpretation and the handoff instead of retyping the same information.

The prototype demonstrates information reuse. Full-workflow staff-time savings and faster authorization have not been measured.

Start with the clinic case

First walkthrough · PCP to SNF

BROOKS, Evelyn

Start with Gather referral records in the Care coordinator / RN role. Follow the six guided steps, review the prepared records and continue through each explicit handoff. Numbered steps explain the workflow; future steps are previews. Open Records, forms & history to inspect the evidence. This case demonstrates PCP-authored skilled-need documentation without making a separate PT note universally mandatory.

Then compare · ED to SNF

REED, Samuel

Select Reed in the case list to explore the ED provider note, hospital PT assessment and ED case-management workflow for a stable pelvic-fracture scenario. See how transfer-day review updates time-sensitive information and revisits home-service availability.

You will demonstrate several teams' responsibilities. Use Continue as… when the guided handoff changes the responsible team. These are not all tasks for one clinician; changing roles records no approval.

Open the fictional SNF prototype Discuss this workflow

No sign-in or upload. Both cases use prepared fictional records. Refresh or Reset demo restores the starting examples.

Automation safeguards: what the system must verify

These safeguards prevent the automated workflow from marking a referral complete before the required human actions and handoffs are confirmed.

  • Sending a packet does not confirm the SNF received it.
  • Preparing a form does not replace the required professional signature.
  • Reviewing source information does not replace a clinician’s decision.

The medication handoff illustrates these safeguards. An early transfer workflow could appear complete while last-dose information was old and original-prescription delivery was still only planned. The revised workflow requires a current departure report and a separate receiving-SNF receipt, while preserving earlier evidence and reviews.

All cases, records, AI proposals and communications are simulated. No live EHR, Florida HIE/CRISP, payer or pharmacy is connected. CMS references support documentation review; the prototype does not determine coverage or clinical suitability and is not intended for patient care. Public references do not imply organizational adoption or endorsement.