Marcia Marshall of San Mateo, California, credits Ward with enabling her husband, Harry, suffering from Parkinson’s disease and other health issues, to “die with dignity.” She explained that “when I reached out to her, I heard from her immediately. She always said, ‘I’m coming by.’ I’m 79 years old, and the last time I had a doctor come to the house, I was a child. I didn’t know doctors still did that. Harry was very fond of her, as am I.”

Prior to Ward’s arrival at Stanford, community-based private practice doctors took charge of care for their patients in SNFs. These facilities take on the most challenging patients to free up hospital beds for those who require a higher level of acute care and avoid the risks inherent in sending patients back to the community before they are ready. SNFs care for some of the most complex cases in the healthcare system, including elderly patients with multiple comorbidities, transplant recipients, and those who have recently undergone surgery for hip fracture. 

“For patients, better communication means better long-term care planning and often reduced hospital readmissions. For caregivers and their families, the SNFist approach offers much-needed support during an extremely stressful time.”

But SNFs acted like information vacuums, with little or no communication between the SNF and the discharging hospital or the patient’s primary care physician. SNFs did not use Stanford’s electronic health record (EHR) system, so established routes of communication were lacking. “So much information is lost between transitions,” says Ward. Moreover, patients in SNFs are mandated to be seen by a physician only once a month, which may not be frequent enough to nip problems in the bud and prevent avoidable hospital readmissions.

Ward solved the problem by appointing geriatrics-trained physicians known as SNFists. Now, after hospital discharge and admission to an SNF, patients are assigned to an SNFist, who oversees care in the SNF, visiting them in the facility about twice a week. “When the patient is ready to be discharged and go back home, the Stanford SNFist contacts the patient’s primary care physician and gives them [the information and support they need to care for the patient in the community]. We are all [inputting patients’ health information] in Stanford’s [EHR], so there is full transparency about the patient over the continuum of time,” she says.

Katherine T. Ward, MD, chatting with a patient.

For patients, better communication means better long-term care planning and often reduced hospital readmissions. For caregivers and their families, the SNFist approach offers much-needed support during an extremely stressful time. 

Before connecting with Ward, Marshall says, there was an “endless cycle” of nursing homes, hospitalizations, and discharges home for her husband, a pattern that degenerated until he came under Ward’s care. “She was absolutely outstanding, and Stanford was outstanding,” says Marshall. “Dr. Ward had a treatment plan for Harry, and her frequent visits to Harry in [the SNF] ensured that her plan was being followed. Without her presence and oversight, little, if any, of that would have been followed. The level of his care was absolutely better because of her oversight and presence.”