Comprehensive Collaboration for Improved Care Transitions With PAC Management

In healthcare today, health plans, health systems, and post-acute care providers are answering a vital call: improving care transitions. Increasingly, it is becoming clear that real-time visibility into meaningful data drives improved collaboration, enhanced patient outcomes, and greater financial returns.

To better understand the dynamics involved in solving the current challenges in managing transitions of care, we sat down with PointClickCare’s Cathy Guttman, Associate Director of Value Based Care, and Adam Delmolino, Senior Director, Virtual Care and Clinical Affairs at the Massachusetts Health & Hospital Association (MHA).

Breaking the Gridlock and Readmission Cycle

PointClickCare offers unique solutions that help overcome the cycle of gridlock that too often impedes effective care transitions. “On a month-to-month basis, we have up to 2000 patients in Massachusetts that are stuck in our hospitals and waiting discharge to a post-acute care facility,” shared Delmolino. “The post-acute care providers play a critical role in addressing so many of the capacity constraints that we’re seeing in our acute care hospitals in Massachusetts.”

Three strategies to support effective collaboration between acute and post-acute providers include: developing a preferred provider network, building effective care collaboration, and gaining clear visibility into patient status.  To help accelerate throughput, PointClickCare’s PAC Management tool connects hospitals and post-acute providers through a common platform providing real-time insights that reduce the unnecessary readmissions that exacerbate the capacity crisis.

A Stronger Network

The right data can help providers at the very beginning of a care transition by both guiding post-acute placement and building a stronger network. “PAC Management’s network scorecard really helps organizations look at readmission rates compared to length of stay, and to look at it from a diagnosis-specific perspective,” explained Guttman. When a skilled nursing facility (SNF) has strong diagnosis-based outcomes, it becomes easier to put data-driven information in front of care coordinators, patients, and families to guide the best post-acute placement choice. “We have to be really mindful of making a sustainable discharge plan,” agreed Delmolino.

In addition, this data helps pinpoint opportunities on both sides to improve care delivery through collaboration. With deep insights, Guttman explained, an organization can take proactive action based on specific outcomes. “For example, can we work together to develop clinical protocols to treat in place, if we see something like high rate of return to hospital for shortness of breath.”

Delmolino also recognized this collaborative potential. “One of our providers was looking for skilled nursing facilities that have experience with a specific type of tracheostomy,” he shared. In realizing the potential to build a stronger network by bringing resources together, the hospital was able to collaborate around helping the facilities’ nurses learn how to use the devices.

Improving Consistency in the Quality of Communication

Enabling effective collaboration between acute and post-acute providers involves clear, consistent communication and a level of clinical detail that supports constructive conversations about patient care. “PAC Management provides the data needed to allow organizations to solve problems together and collaborate on care, which reduces returns to the emergency department,” explained Guttman. Instead of focusing on surface-level details, healthcare teams can easily retrieve basic information and instead have conversations about a patient’s overall risk and trends. “It’s more about being proactive than reactive.”

Delmolino also stressed the importance of communication. “Do we have a full picture of what a patient might need and did all that information get transferred over from the hospital to the skilled nursing facility? That is something the PointClickCare model can be really effective at assisting with — looking at population health and making sure that every provider has the information that they need about that patient and can make decisions and take steps to make sure that they’re not missing an opportunity to address something, whether it’s medication reconciliation, contact with a family member, or a behavioral health need, for example.”

It’s that comprehensive ability of the PointClickCare systems to share detailed information that helps reduce challenges like duplicative testing, unnecessary costs, and inefficiencies, explained Guttman. “When a patient does return to the hospital from the SNF, the data visibility supports triaging of that patient, so that instead of keeping the patient for more tests because the ED doesn’t know what’s going on, they can safely discharge back to the SNF if appropriate.”

Innovating for the Future

Ultimately, having access to PAC Management’s real-time data allows both acute and post-acute providers to move beyond just solving today’s collaboration challenges. As the healthcare industry evolves this ability will prove even more valuable.

For example, the TEAM model, which is starting in 2026, is CMS value-based payment model for five different surgical procedures affecting providers. It’s one of many like it that are sure to roll out in coming years to meet CMS’ goals for value-based care. This highlights the critical importance of visibility along the continuum of care, Guttman noted. “PAC Management creates a line of sight even after the patient leaves the SNF. That’s essential, because the system is responsible for the cost of care from 30 days from the date of surgery. This allows the ambulatory team an opportunity to better manage that patient post-discharge to decrease the risk of a return to the hospital.”

With patient outcomes at the center of care innovation, data will continue to differentiate providers who can respond appropriately to complex patient insights and needs to reduce the rate of return to the hospital and the overall cost of care. For example, both Guttman and Delmolino suggest that the growing need to identify patients who could benefit from a conversation about another growing care intervention — palliative care — will be another reason why this is imperative.

In Massachusetts, as Delmolino was quick to point out, “The state is putting together and will be in charge of a throughput task force that’s going to be looking at case management and care transitions to develop recommendations that potentially could either turn into new policies, regulations or legislation to address these issues.” Forward-thinking organizations who leverage technology solutions to accelerate improvements in readmission rates and throughput will remain ahead of any developing changes. To learn more about how PAC Management can help you enhance care collaboration across the post-acute care continuum, connect with us today.