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Break the Cycle of Rehospitalization by Optimizing Care Transitions Across the Continuum

Traditional approaches to patient transitions from acute to post-acute care typically consist of the transfer of the patient, a stack of paperwork, little to no report, and limited interaction between settings. This can lead to unnecessary complications such as medication errors and preventable infections. The introduction of value-based payment models and penalties for hospital readmissions has motivated providers to improve transitions to post-acute facilities and home-based care, but challenges remain.

This session explains how post-acute analytics helps break down communication silos to connect health care organizations, optimizing transitions of care and patient management. Participants will learn how leveraging live data from their post-acute partners enables them to identify the most appropriate post-acute care setting based on the patient’s needs, enhance care coordination and patient education efforts, and define standards of care based on clinical pathways. Working together from the same data, acute and post-acute providers can also improve clinical outcomes by setting shared goals, establishing a discharge date and plan, and understanding the level of rehabilitation patients need. We will explore how data transparency with post-acute partners provides hospital care teams clinical line of sight to ensure patients are managed effectively in place, breaking the cycle of rehospitalization.