Post-Acute Transitions: Closing the Information Gap

Coordinating care and maintaining patient oversight after an individual leaves your facility can be challenging.

Patients transitioning to a skilled nursing facility (SNF) represent a fragile, medically complex population at higher risk of adverse events and rehospitalizations.

Both the acute and post-acute care teams struggle to manage these transitions effectively due to the following:

• Automation and information gaps: EHRs may not support bi-directional connectivity and data exchange to outside platforms
• Manual inefficiencies: Paper, phone, and fax continue to be primary alternatives for sharing information, incurring a greater chance of errors or omissions
• Patient and data visibility: Data can be fragmented, delayed, or completely unavailable

The lack of visibility in either setting can overlook gaps in information, delay critical warning signs, and timely interventions. Given the impact of penalties for avoidable readmissions, hospital providers need  up-to-date information at their fingertips.

Below, we explore two steps for streamlining post-acute transitions.

Real-Time Data for Real-Time Decisions

To provide extended care coordination, hospitals must be able to:

• Share clinical data with their SNF partners to ensure seamless care continuity
• Stay informed of a patient’s risk levels and status, such as vitals, ADLs, medications, or labs
• Ensure that medication regimens stay as prescribed
• Collaborate or quickly intervene with support or proactive measures

When hospitals can follow the performance of their post-acute network partners, like tracking patient census, readmissions, or average length-of-stay metrics, they are not only able to recommend patients for facilities with the best operations, but they can also directly influence partner outcomes by highlighting areas for correction.

A Better Network for Better Outcomes

Historically, acute providers didn’t have access to post-acute partner data and information to optimally manage transitions and partner performance.

PointClickCare provides hospitals and risk-bearing entities a solution that can fill the information gaps required to streamline patient transfers, reduce readmissions, improve clinical outcomes, and manage their post-acute partner networks.

PAC Network Management offers:

• Bi-directional connectivity between the hospital and the largest post-acute network in the country
• Visibility to real-time, trusted data about the patient throughout a post-acute stay and any subsequent readmissions
• Visibility into partner performance metrics designed to promote better network partner management and improvement