Cynthia Burghard

The perfect storm of mis-aligned supply and demand contributes to the current crisis in post-acute care delivery. Addressing staffing shortages and the demands of an aging, and sicker patient population requires system wide changes, but data can ease the burden of post-acute care placement and transition.

Supply and Demand Misalignment

Post-acute care patient placement has always been fraught with challenges that include the lack of quality of care data, poor transition hand offs, lack of availability of an appropriate bed, and, of course, the inability of patients to afford long term care. In recent years the misalignment of supply and demand exacerbated these challenges. The gating factors for smooth transition from acute to post-acute today are bed availability and the lack of interoperability resulting in incomplete and inaccessible patient data.

“Nursing homes are facing a historic workforce crisis brought on by the pandemic. According to the Bureau of Labor Statistics, the sector has lost nearly 229,000 caregivers (or more than 14 percent of its workforce) since February 2020, the worst job loss among all health care sectors. The lack of available staff has forced more than 60 percent of nursing homes nationwide to limit new patient admissions – impacting hospitals that are seeking to free up precious beds and preventing seniors from accessing the care they need.”1

What makes this a perfect storm is that coupled with limited supply, the demand for long term care is increasing. The challenge is further exacerbated for those with special needs such as cognitive impairment and those who are economically insecure.

  • The demand for long term care is predicted to grow, the U.S. Census 2020 reports that about 1,290,000 Americans currently reside in nursing homes. That number is expected to nearly double by 2050.
  • A recent survey from the National Council on Aging indicates that 80% of aging Americans cannot afford to pay for Long Term Care or withstand a financial shock. 2

Structural changes such as aligned incentives and an increase in home care options are clearly needed that are out of the scope of this blog, but experts we have spoken to have identified two key areas where data can reduce the friction on transitions from acute care hospitals to facility or home-based care. Standardizing discharge algorithms to predict a patient’s specific post discharge needs early in a hospital stay enables a more targeted placement approach. When key patient data is electronically transferred from acute care to long term care facilities a smooth and efficient transition can be accomplished. Today nurses in long term care facilities spend up to 2 hours per patient hunting down and manually entering patient data into post-acute facility medical record systems.

Standardizing Discharge Algorithms to Improve Hospital Throughput

Improve Complex Patient Outcomes

The limited supply of skilled nursing home beds, particularly for complex cases, causes throughput bottlenecks for hospitals. We spoke with Kristi Short, Executive Vice President, Care Networks at Navvis, a population health, value-based care services company ( to gain insight into various approaches to improve hospital throughput.

She emphasized the need to increase throughput to allow hospitals to place patients in the most appropriate care setting. Delaying admissions because beds are tied up with patients awaiting discharge limits access to care and does not deliver the best quality of care possible.

Some of the strategies she shared include establishing pre-paid bed reservations to ensure bed availability particularly for frail and complex patients, and cost sharing between the acute and post-acute facility for expensive items such as medications. Ms. Short indicated, “Increasingly, discharge planning goes beyond the clinical needs of patients and discharge plans must account for social or economic factors such as homelessness.” 

She went on to explain that, today, discharge assessments collect important information on a patient’s condition and anticipated needs, but standards are not in place to make recommendations as to what post discharge care is most appropriate. Creating algorithms that use data from the assessments and other sources to determine/recommend placement as early into the inpatient stay as possible facilitates a timely placement.

Algorithms must take into consideration the benefits of discharging even complex patients, home. The pandemic forced the industry and CMS to adopt and reimburse the delivery of clinical services at home for patients that were once thought to require care in a post-acute care facility. While most patients and family members prefer care delivered in their home, the needs of some patients require a skilled nursing stay.  Matching patient needs and settings of care to deliver the best outcome is the objective.

Codifying and analyzing data to build algorithms that identify the “best” post discharge setting should reduce the friction that occurs with delays in patient discharge from acute care hospitals. Patients languishing in acute hospitals waiting to be discharged results in lost revenue for hospitals.

Post-acute Efficient and Timely Transitions

Improve Complex Patient Outcomes

Fragmented communication, failure to complete safe handoffs, and missing patient data throughout the transition from acute care hospital to home or long-term care facility is associated with a high risk of medical errors and adverse events.

Approximately one in five hospitalized patients are readmitted within 30 days and a third of patients are readmitted in 90 days. A recent systematic review of 54 moderate to high-quality studies found that about half of older adult patients transitioning from the hospital to community settings were affected by at least one medical error and 20% were affected by one or more adverse events. 3  

We have all heard the horror stories of patients arriving at the doorstep of a post-acute care  Facility with virtually no information regarding their clinical or social history. It stands to reason that enabling collaboration and access to real-time insights at every stage of the patient’s healthcare journey helps to avoid these unnecessary readmissions. In an interview, Anthony Laflen, Acute and Payer Market Leader, PointClickCare ( shares,

“Post-acute nurses can spend up to 2 hours tracking down and inputting data from a referring hospital. It’s no wonder that the retention of nurses in Skilled Nursing is so challenging.  Afterall, most did not become a nurse only to spend their time entering data.”  

To further streamline the transition to post-acute care, the PointClickCare platform has embedded direct access to the national Carequality interoperability framework to enable nationwide care coordination. Laflen continues, ”We are calling this free resource PointClickCare Connect, as it empowers our customers to exchange information between and among over 4,200 hospitals, 600,000 care providers, and 1.4 million active resident and patient records,” Laflen said.

With a single click, a user can access the most recent Continuity of Care Document (CCD) from the patient’s hospital acute stay and pull the information directly into the EHR of the long-term care facility. This complimentary access to Carequality has dramatically increased the efficiency of the staff by cutting documentation time from an estimated 2 hours to less than 30 minutes per admission so more time can be spent helping a patient thrive in the post-acute setting.

According to Laflen, while the results of PointClickCare Connect are still pending, they do know that the nurses working in their customer’s facilities are practicing at the top of their license.  Patients are getting expedited care on admission and the availability of patient data is improving care quality and reducing errors.

Parting Thoughts

Not even copious amounts of high-quality data can solve the systemic problems facing post-acute care and including the overwhelming number of older, sicker patients. Data, however, can be applied to reduce the friction of patient placement into post-acute care resulting in the efficient and timely transfer of patients between these two settings.

Healthcare organizations have long used data to support internal and external reporting without delivering data at the point of decision-making. Data is the new currency in healthcare and through the development of interoperability standards and advanced analytics including AI algorithms, the ability to deliver insights is growing and can be applied to challenges faced in identifying which post-acute care setting is best for a patient and enabling a smooth transition.

To address the significant friction caused by delayed post-acute care placement and care transitions between facilities, healthcare organizations should:

  • Reduce discharge backlogs – review discharge assessment processes and develop algorithms to standardize and predict post-discharge needs of patients across the enterprise. Be prepared to evaluate the best discharge option for patients and include discharge home along with facility-based care. Resources, including reimbursement for home-based care are rapidly emerging.
  • Avoid adverse patient outcomes resulting from missing patient information and improve efficiency – take advantage of interoperability frameworks and standards to electronically exchange patient data between acute care and post-acute care facilities to ensure a smooth transition across settings. Reducing the time it takes a nurse to admit a patient and develop a care plan benefits both patients and nurses.


  1. Historic Staffing Shortages Continue To Force Nursing Homes To Limit New Admissions, Creating Bottlenecks at Hospitals and Reducing Access To Care For Seniors (
  2. 80% of Older Americans Cannot Pay for Long-Term Care or Withstand a Financial Shock, Nes Study Shows
  3. Post-Acute Transitonal Services: Safety in Home-Based Care Programs

As always, I welcome your thoughts and encourage you to reach out to me with questions or for a conversation.