Health System and ACO Reduces Readmissions and Blind Spots With PAC Management IQ
PeaceHealth eliminates SNF blind spots and manages post-acute risk with PAC Management IQ
About PeaceHealth
PeaceHealth is a not-for-profit health system and ACO founded in 1890 and serving communities across Washington, Oregon, and Alaska through a network of medical centers, critical access hospitals, and clinics. Their care touches 25,000+ lives across the continuum.
Learn how PointClickCare helped PeaceHealth improve readmission rates, reduce ED visits and inpatient length of stay, and achieve shared savings within ACO REACH.
“We had a real problem. Patients were discharging to skilled nursing facilities and readmitting to the ED, and nobody had visibility into what happened in between. We built a team, put PAC Management IQ in their hands, and that’s what drove meaningful improvements in readmissions and outcomes. The team monitors patients daily and reviews rising-risk cases in weekly IDT meetings, intervening same-day when condition changes are flagged.”
Daleasha Hall
System Director for Value-Based Care, PeaceHealth
The Challenge
PeaceHealth faced a critical visibility gap once patients transitioned from the hospital to skilled nursing facilities, with little insight into their members’ status, medications, or readmission risk.
Limited Post-Acute Visibility
No visibility into patients after SNF transition (“black hole”).
Lack of Information
Incomplete information across medications, patient condition, and care plans.
Workflow Inconsistency
Post discharge workflows weren’t consistently executed.
Care Coordination Gaps
Fragmented coordination across care settings.
The Solution
PeaceHealth chose PointClickCare’s PAC Management IQ for real-time visibility across skilled nursing facilities.
Stronger Care Teams
Formed a dedicated Post-Acute Care Collaborative team.
Earlier Intervention
Established daily risk identification and post-discharge workflows, with weekly IDT meetings to review rising-risk patients.
Real-Time Clinical Insights
PAC Management IQ provides real-time visibility across SNFs and flags changes in patient condition.
The Outcome
Top 2%
Nationally for all-cause readmission reduction
Lower than average
LOS and SNF admission rates compared to market averages
Since launching its post-acute management team—enabled by PAC Management IQ—PeaceHealth’s ACO now ranks in the top 2% nationally for all-cause readmission reduction, with performance holding in the 99th percentile year over year.
PeaceHealth leveraged PAC Management IQ as part of its people, process and technology approach to strengthen performance across PeaceHealth’s value-based care populations. SNF admissions, admissions per 1,000, average length of stay, and cost of care all now beat market averages across its ACO, CIN commercial, and other Medicare Advantage populations.
“PointClickCare’s PAC Management IQ tool has been extremely important to the success of our transitions team,” notes Daleasha Hall, System Director for Value-Based Care at PeaceHealth. “We have a relationship with our collaborative [post-acute care] facilities where we can have bidirectional data exchange and really have that transparent care plan to help us have eyes and ears on patients once they leave the hospital.”
These gains translated directly into financial and clinical results: PeaceHealth achieved shared savings and qualified for the ACO REACH High Performers Pool, while contributing to reduced ED visits and shorter inpatient stays across its ACO REACH population.
Hall shares, “If a patient goes to a skilled nursing facility and no one is paying attention, there’s not a lot of knowledge on the care they’re receiving or what their trajectory is. PAC Management IQ is what keeps someone paying attention to that whole process.”
Clinical Data Exchange
Real-time clinical insights with collaborative SNFs deliver transparent care plans and support safe SNF discharges.
Wins Across Populations
Stronger results across ACO, CIN commercial, and Medicare Advantage populations, with cost of care below market.
Shared Savings Achieved
Achieved shared savings and qualified for the ACO REACH High Performers Pool.
Fewer ED Visits and Shorter Stays
Contributed to reduced ED visits and shorter inpatient stays across its ACO REACH population.
Take a closer look
Explore how PAC Management IQ can help your organization improve post-acute outcomes.
Hear About PeaceHealth’s Experience