How to Implement Post-Acute Care Management Technology in Your Hospital

Is your hospital struggling with inefficient patient transfers to post-acute care (PAC)? 

You’re not alone. As the aging baby boomer population grows, the demand for PAC is rising. 

But there’s a major gap—many PAC facilities still lag behind hospitals in technology.

For example, some senior living facilities don’t even have electronic health records (EHRs). 

This leads to missing or delayed patient data, increasing the risk of preventable readmissions and higher costs. 

The problem is even worse for long-term care facilities, many of which rely on Medicaid and operate on thin margins. 

Waiting a month for a discharge summary? That’s just too long.

Technology can fix this. In this blog, we’ll explore tech-driven strategies like real-time data sharing, AI-powered tools, and seamless communication platforms. 

The goal? To ensure acute-care clinicians have access to complete patient data—at the right time, in the right place—so they can make the best care decisions.

The Problem with Post-Acute Care Transfers

Patient transfers to post-acute care (PAC) have long been inefficient. Many facilities still rely on outdated, paper-based processes. 

This creates serious challenges for hospitals, PAC providers, and—most importantly—patients.

Here’s what typically happens: A patient is discharged from the hospital and arrives at a PAC facility with a stack of paper forms. 

These forms contain critical medical information, but they’re not always complete, and they’re easy to misplace. 

Meanwhile, care managers at the hospital try to stay updated through fax or phone calls, which is slow and unreliable.

The biggest issues with this outdated system include:

• Communication Gaps: Hospitals and PAC providers often struggle to exchange patient updates quickly. Fax and phone calls just don’t cut it anymore.
• Delays in Information: Waiting weeks—or even a month—for a discharge summary is simply too long.
• Lack of Real-Time Data: Without instant access to patient updates, hospitals can’t intervene when problems arise. This can lead to serious health complications.
• Limited Technology in PAC Facilities: Many senior living centers still don’t have electronic health records (EHRs), making data-sharing even harder.

The impact of these inefficiencies is huge:

• Patient Deterioration: If care teams don’t catch warning signs early, patients can decline quickly, leading to emergency department (ED) visits.
• Higher Costs: Unnecessary ED trips and rehospitalizations strain hospital resources and hit value-based care programs hard.
• Poor Patient Outcomes: Without smooth care transitions, recovery takes longer, and patients suffer.

Right now, post-acute transfers feel like a “black hole.” Hospitals discharge patients and lose visibility into their condition. This lack of coordination makes it tough to provide high-quality care.

The Role of Technology in Transforming Post-Acute Care

Technology is changing the way post-acute care (PAC) is managed. It helps hospitals and PAC facilities work together more efficiently, improving patient outcomes and reducing unnecessary costs.

1. Real-Time Data and Insights

With real-time data, care managers can monitor patients in skilled nursing facilities (SNFs) and intervene before a health crisis occurs.

This prevents avoidable emergency department visits and rehospitalizations, which are costly and disruptive to patient care.

• Real-time access to patient information allows providers to make quick, accurate decisions.
• Early intervention reduces hospital readmissions and improves overall patient health.

2. AI and Machine Learning

AI-powered tools are becoming a key part of PAC management.

Machine learning can analyze vast amounts of patient data and predict which patients are at high risk of readmission.

• AI models can predict patient deterioration with greater accuracy than traditional methods.
• These tools automate administrative tasks, such as physician note generation, reducing the burden on staff.
• AI-powered scheduling ensures better resource allocation, improving efficiency.

3. Interoperability and Common Platforms

Many PAC facilities still operate without electronic health records (EHRs), creating delays in patient data sharing.

A common platform between hospitals and PAC providers can close this gap.

• Integrated EHRs allow seamless data exchange between hospitals and PAC providers.
• A real-time communication channel ensures all care teams have up-to-date patient information.
• Optimized network management services improve healthcare workflows and data security.

By adopting these technologies, hospitals and PAC providers can work more effectively, leading to better patient care and lower healthcare costs.

Specific Technologies and IT Services for Post-Acute Care

To revolutionize post-acute care, several key technologies and IT services can be implemented:

1. Electronic Health Records (EHRs)

EHRs store and manage patient medical data, giving providers a complete view of a patient’s health history. When integrated across different care teams, EHRs:

• Ensure smooth data sharing between hospitals and post-acute care facilities.
• Allow providers to access real-time patient information for better decision-making.
• Help care teams plan discharges more effectively.

2. Telehealth and Remote Monitoring

Telehealth makes it easier for providers to care for patients after discharge, reducing the need for hospital visits. Remote monitoring devices track vital signs, helping providers detect health issues early.

• Virtual visits let doctors and nurses check on patients from anywhere.
• Patients can manage their conditions with remote support from their healthcare team.
• At the Cleveland Clinic, virtual visits jumped from 37,000 in 2019 to 1.2 million in 2020, showing the rising demand for telehealth.
• Smart devices integrated into telehealth visits provide real-time health data, leading to better diagnoses.

3. Mobile Applications

Mobile apps help patients stay on top of their health after discharge.

• Medication reminders ensure patients take their prescriptions on time.
• Apps track symptoms and recovery progress, alerting providers to any issues.
• Patients can connect with caregivers and support networks for ongoing guidance.

4. Data Analytics and Predictive Modeling

Data analytics helps healthcare teams make better decisions by identifying trends and risks. Predictive modeling uses patient data to:

• Forecast potential health problems so care teams can act early.
• Improve resource allocation and staffing, ensuring efficient care.
• Identify patients at high risk of readmission and adjust their treatment plans.

By adopting these technologies, hospitals and post-acute care providers can enhance patient care, reduce readmissions, and create a more connected healthcare system.

Architecture of Our Remote Patient Monitoring System 

Our Solution for Post-Acute Care: A Closer Look

At SyS Creations, we provide a powerful post-acute care (PAC) management solution that helps hospitals and healthcare providers coordinate seamlessly with post-acute partners. 

By leveraging real-time insights and predictive analytics, we enable smoother care transitions and better patient outcomes.

How Our PAC Management Solution Helps:

• Real-Time Patient Tracking: Care teams can monitor patients throughout their post-acute journey and intervene when necessary, reducing avoidable readmissions.
• Readmission Prevention: Identifies patients at high risk of rehospitalization and supports timely intervention, helping prevent unnecessary ED visits.
• Improved Network Performance: Leverages real-time network scorecards to track key metrics such as 30-day readmission rates and SNF average length of stay (ALOS).
• Seamless Transitions: Our real-time Admits & Discharges tool ensures smooth handoffs between hospitals and SNFs, preventing communication gaps.
• Quality Insights: Tracks and compares CMS quality metrics, including quality management, health inspections, staffing ratings, rehospitalization, and ED visit rates for PAC providers.
• Enhanced Collaboration: SNFs get access to a Partner Toolkit that provides shared performance metrics, allowing for better coordination and patient management.

Additionally, our Predictive Return to Hospital Algorithm enhances patient monitoring by enabling proactive interventions. 

The Financial and Clinical Benefits of PAC Management

Managing post-acute care (PAC) efficiently brings both financial and clinical benefits. With better care coordination, fewer readmissions, and optimized stays in skilled nursing facilities (SNFs), providers can improve patient outcomes while controlling costs.

How PAC Management Helps:

• Fewer Hospital Readmissions: By closely monitoring patients after discharge, providers can identify high-risk cases early and intervene before hospitalization is needed. This prevents unnecessary hospital visits and improves recovery.
• Optimized SNF Length of Stay: Patients should not stay in SNFs longer than necessary—but they also shouldn’t leave too soon. PAC management ensures timely and safe discharges using real-time patient data.
• Better Care Coordination: Connecting hospitals and post-acute facilities with real-time insights helps providers make informed decisions and offer seamless transitions for patients.

Real-World Impact

• TriHealth reduced readmissions by 68% and cut SNF length of stay by 28% using PAC Management.
• Sentara Health reported lower in-network costs and fewer readmissions (both in-network and out-of-network) after implementing PAC Management in January 2024.

Overcoming Barriers to Technology Adoption in Post-Acute Care

Adopting new technology in post-acute care isn’t always easy. Many providers worry about high costs, while medical staff may resist change. 

When EHRs were first introduced, smaller practices struggled with adoption. The same concerns exist today with new healthcare IT solutions.

To make the transition smoother, working with an experienced healthcare IT partner can help. At SyS Creations, we assist post-acute care providers in:

• Assessing Needs: Understanding what technology is necessary for your facility.
• Choosing the Right Solutions: Selecting tools that improve care without disrupting workflows.
• Seamless Implementation: Ensuring a smooth rollout with minimal disruption.
• Training Staff: Helping caregivers and administrative teams get comfortable with new systems.
• Ongoing Support: Providing continuous monitoring, troubleshooting, and upgrades.
• Secure Data Transmission: Ensuring EHRs and other applications run efficiently and safely.
• Reliable Communication: Enhancing caregiver-patient communication for better care coordination.

With the right support, post-acute care facilities can embrace technology without the headache. SyS Creations ensures that healthcare IT works for you—not against you.