Shaping the Future of Discharge Planning with AI: PAC Management’s Approach to the Post-Acute Care Gap
5 min
ACOs & Risk-Bearing Providers, Health Plans, Hospitals & Health Systems
Discharge from a skilled nursing facility (SNF) marks a critical juncture in a patient’s care journey. It’s also where coordination often breaks down. For hospitals, Accountable Care Organizations (ACOs), and health plans, this process can determine whether a transition is safe, timely, and cost-effective—or whether it leads to delays, readmissions, and missed follow-ups. Today, discharge planning is more than a clinical task; it’s essential for effective care coordination and organizational success.
What’s Driving the Pressure?
Organizations across the care continuum face mounting demands. Hospitals must manage patient flow with precision, as throughput now directly affects financial performance. ACOs are tasked with controlling costs across fragmented networks while maintaining quality. Health plans are held to increasingly rigorous standards for member outcomes and documentation. Several forces are converging to intensify these pressures:
- Value-based care is accelerating, requiring tighter coordination across settings.
- TEAM regulations, effective January 2026, will hold hospitals accountable for total episode cost and quality 30 days after procedures.
- CMS has flagged discharge documentation gaps as a compliance risk.
- Health plans face blind spots in member location, clinical status, and discharge support—issues that directly impact readmission likelihood, HEDIS and Star ratings.
Why SNF Discharge Summaries Are Still a Problem
Unlike acute care EMRs, SNF systems aren’t required to produce standardized discharge summaries. Instead, discharge-relevant information is scattered across progress notes, therapy documentation, and orders. Many SNFs continue to use traditional workflows—such as faxing, phone calls, and chart reviews—to communicate updates. While these methods have supported care teams for years, they can sometimes result in gaps or delays in sharing important discharge details, especially when transitions need to be timely and precise. This can make it more challenging to ensure all relevant information is available for smooth patient transitions and optimal outcomes.
How PAC Management Is Solving for Discharge Planning
PAC Management addresses these challenges by surfacing the most relevant discharge-related information—whether structured or unstructured—so care teams can act quickly and confidently. This includes visibility into active medications, therapy notes, orders, progress notes, estimated discharge dates, and predictive risk scores.
Building on these capabilities, PAC Management is now able to generate full Discharge Assessments, providing care teams with the official documentation required to complete discharge planning. This ensures that all necessary details are captured and available for a safe, compliant transition.
Looking ahead, PointClickCare is developing AI-powered capabilities for PAC Management that will enable care teams to automatically surface any and all discharge-relevant clinical details—eliminating the need for care managers to manually search for them. This feature will further streamline the discharge planning process, making it even more efficient and comprehensive.
Where SNFs use structured discharge assessments, PAC Management makes these available with patient consent, offering consistent, high-quality information that supports safe transitions. For facilities that rely more heavily on narrative documentation, PAC Management is developing AI-powered summarization to extract and present discharge-relevant details in a standardized format. Together, these capabilities ensure that discharge-critical information is accessible, complete, and actionable—regardless of how or where it was documented.
What This Means for Hospitals, ACOs, and Health Plans
The ability to see and act on discharge information—without chasing it—is a game changer. PAC Management brings together the most relevant details in one place, whether from structured assessments or unstructured notes.
- Hospitals benefit from a clearer picture of when a patient is likely to discharge and what services they’ll need afterward. This helps avoid last-minute scrambles and supports smoother transitions to home health, outpatient therapy, or follow-up appointments. It also reduces the risk of readmissions, which are costly and increasingly tied to performance metrics.
- ACOs, tasked with managing total cost of care, gain visibility into discharge readiness and care plans that often go undocumented in traditional EMRs. With PAC Management, they can intervene earlier, align services more effectively, and ensure that patients don’t fall through the cracks during transitions.
- Health plans often don’t know where their members are or what care they’re receiving until after the fact. PAC Management helps close that gap by surfacing real-time discharge signals and care documentation. This supports better coordination with providers, improves documentation for quality measures like HEDIS and Star ratings, and enables more proactive outreach. Additionally, health plans’ care managers can play a crucial role by ensuring members have the necessary supports—such as DME, home health services, and other resources—upon discharge to help prevent readmissions.
Across all three audiences, the value lies in moving from fragmented, delayed updates to timely, actionable insights. Whether the information comes from a formal assessment or is extracted from progress notes using AI, PAC Management is solving for the same goal: making discharge planning more predictable, more complete, and more collaborative.
Final Thoughts
Discharge planning has moved from behind the scenes to the point of care, influencing how well patients recover, how much care costs, and whether organizations meet compliance standards. PAC Management is helping care teams move from reactive to proactive—by making discharge information visible, usable, and actionable. As AI-powered capabilities come online, the future of discharge planning will be defined by clarity, not complexity. And for hospitals, ACOs, and health plans, that clarity will be key to delivering better care at lower cost.
