Internal Alignment to Early Results: One Health System's Post-Acute Transformation

Managing patients across the post-acute continuum--entering, residing in, and transitioning out of skilled nursing facilities--has long challenged health systems. Limited visibility into patient status and fragmented workflows often lead to delays, inefficiencies, and missed opportunities. One large multi-state health system recognized that improving care management required a new approach: one providing real-time insights and connecting clinical, operational, and IT teams beyond the EHR.

In this session, organization leaders will share how they identified gaps in care transitions and developed a strategy to address them. You'll hear how they partnered with IT to align on necessary capabilities beyond their tech stack, secured buy-in, and integrated new solutions without disrupting workflows. This journey is focused not just on technology, but on collaboration that supports proactive discharge planning, reduces delays, and strengthens continuity of care.

We'll explore early results and lessons learned, including how enhanced visibility enables the teams to tackle post-acute care management challenges. Discussion will also touch on empowering ED providers with insight into relevant clinical information for patients returning from a SNF, and how these efforts complement post-acute strategies.  Attendees will gain practical insights on building consensus, overcoming barriers, and advancing care management.