By Hamad Husainy, DO, FACEP, Chief Medical Officer of Acute & Payer, PointClickCare
LinkedIn: Hamad Husainy DO, FACEP
LinkedIn: PointClickCare
Hospitals are under increasing pressure to minimize readmissions and close costly gaps in care, particularly during the crucial post-acute care (PAC) phase when patients move to skilled nursing facilities (SNFs).
This is the phase when patients are most vulnerable, and even small gaps in care can lead to complications and avoidable readmissions, no small consideration for hospitals.
The U.S. healthcare system pays a heavy price for inadequate care coordination, which includes deficient management of care transitions. Avoidable complications and unnecessary hospital readmissions are responsible for $25 billion to $45 billion in wasteful spending, according to one estimate.
Transitions to SNFs are especially high-risk, as patients often have complex needs that require carefully coordinated handoffs. Poor communication between hospitals and SNFs can result in medication errors, duplicate testing, or missed follow-up appointments, all of which drive up costs and worsen patient outcomes.
With the onset of mandatory value-based care models and penalties for high readmission rates, ensuring a smooth and effective transition during this phase is more critical than ever.
Creating smoother transitions to PAC
Technology that enables real-time information sharing, better care coordination, and proactive monitoring makes a huge difference in ensuring smooth transitions.
One of the most significant barriers to successful care transitions is the “data black hole” that often occurs after discharge. Many ACOs and hospitals lose visibility into patients’ conditions once they leave the acute setting, making it difficult to intervene when problems arise.
Technology that integrates hospital systems with post-acute providers closes this gap, enabling clinicians to track patient progress and intervene early when risks escalate.
Another key challenge is fragmented data across different providers. When patient information is siloed and not easily accessible, care teams risk missing critical warning signs, duplicating tests, or executing conflicting care plans.
Platforms that consolidate clinical data from various sources provide a more complete view of the patient, empowering teams to make timely, informed decisions that support safer transitions.
Predictive analytics also play a powerful role in smoothing care transitions. AI-driven risk scoring models can continuously assess a patient’s likelihood of unplanned hospital returns based on real-time clinical data, contextual progress notes (e.g., pain and agitation levels), and other readmission risk factors.
These insights can be embedded directly into clinical workflows, helping care teams prioritize high-risk patients and adjust care plans accordingly. Early detection of issues such as changes in mobility, vitals, or medication errors allows for proactive intervention that can prevent hospital readmissions.
For frontline staff, the burden of managing transitions is often compounded by disconnected systems and manual processes. Streamlining discharge planning and care coordination with automated workflows helps standardize transitions and reduce clinician burnout. These tools not only improve efficiency but also ensure that patients are referred to the most appropriate post-acute provider based on quality metrics and care needs.
Strong SNF relationships built on shared data and aligned goals create a seamless extension of the hospital’s care continuum. Transparent collaboration communication allows both sides to coordinate treatments, manage medications, and plan follow-up care effectively. Regular performance reviews based on data and outcomes further strengthen accountability and collaboration.
A coordinated, data-driven approach
Managing high-risk patient pathways during the post-acute phase requires a coordinated, data-driven approach that empowers clinicians with real-time insights and predictive tools. By eliminating information blind spots, streamlining workflows, and strengthening hospital-SNF partnerships, healthcare organizations can reduce readmissions, improve patient outcomes, and thrive under value-based care models.
With the right technology and strategies, smooth transitions from hospital to post-acute care become not only achievable, but also essential to delivering safer, more efficient care across the continuum.
Hear more from Hamad Husainy, DO, FACEP on Tell Me Where IT Hurts with host Dr. Jay Anders. Together, they chat about real-time intelligence, data quality, and AI in healthcare, focusing on supporting acute care providers and payers to deliver high-quality, real-time data that enables better decision-making at the bedside and across care teams.