Lack of Post-Discharge Visibility Across HIE Networks
Lack of real-time encounter data for transitional care prevents care teams from identifying high-risk patients and acting during critical post-discharge window.
Why Timely Post-Discharge Insight Matters
Health information exchanges enable data sharing across the continuum, but most lack timely insight into what happens after discharge. Without early visibility into post-acute encounters and follow-up care, care teams miss critical windows to identify high-risk patients, coordinate outreach, and prevent avoidable readmissions. Timely, network-level insight transforms transitional care from reactive to proactive. With real-time encounter alerts and coordinated workflows, HIEs can enable earlier intervention, improve follow-up consistency, and support better outcomes across every transition.
What Drives Delayed Intervention
High-Risk Transitions
Care transitions are the highest-risk period, where missed follow-up drives avoidable readmissions and utilization.
Delayed Patient Insight
Medicare claims can take about 11 months to finalize, so claims-based follow-up lags real-time data (CMS).
Post-Acute Blind Spots
Nearly 1 in 4 SNF patients are readmitted within 30 days, the setting least visible to many HIEs (JAMA/CMS).
Fragmented Handoffs
Discharge details often reach the next setting late or incomplete, so follow-up starts without a full picture.
The PointClickCare Network for Transitional Care
The PointClickCare Network delivers timely insight into patient movement across acute and post-acute care. HIEs can identify high-risk patients sooner, coordinate follow-up, and enable earlier intervention during critical periods.
Additional Solutions for Transitional Care Management
PAC Management IQ
Extends visibility into post-acute settings by enriching patient transition data with skilled nursing facility (SNF)-level clinical insight. This enables HIEs and care teams to identify high-risk patients faster, monitor post-discharge activity, and support more timely follow-up during critical transition periods.
Product Capabilities:
Visibility into SNF admissions and post-acute activity
Access to clinical context beyond basic encounter notifications
Earlier identification of high-risk patients in post-acute settings
Supports timely follow-up and reduced gaps in transitions
Emergency Department IQ
Provides timely insight into emergency department utilization to help identify patients at risk of readmission and trigger earlier intervention. By surfacing emergency department (ED) activity quickly, care teams can coordinate follow-up, reduce avoidable utilization, and improve continuity of care after discharge.
Product Capabilities:
Real-time visibility into ED admissions and revisits
Identification of high-utilization and at-risk patients
Supports intervention before readmissions occur
Improves coordination between ED and downstream providers
Health Information Exchange:
Prioritized Population Health Insights
Explore more resources
Talk to an Expert
Connect with an expert to find the right solutions to support your HIE with post-discharge visibility.
Explore Resources
Explore insights and articles on transitional care management for HIEs, plus upcoming events and webinars.