Healing the divide: How digital tech can connect acute and post-acute care
Organizations need to break out of data siloes to enable care managers to improve transitions of care for patients.
Healthcare, as we know it, is changing. More care is shifting outside hospital walls, which is largely beneficial for patients, but only if transitions are handled correctly.
Too often, the move from acute to post-acute care is anything but smooth. Critical information doesn’t always make it to the right people, leading to unnecessary hospital readmissions, frustrated providers, and patients and their families left in a state of uncertainty.
In this case, the underlying issue isn’t a lack of data. It’s that hospitals and post-acute providers don’t always have the right information at the right time. On a positive note, this problem can be fixed with smarter digital tools that create real-time connections between care teams.
What does that look like in action? It involves prioritizing crucial patient information, enabling true two-way data exchange and using technology to match patients with the right post-acute care provider.
Having the right information at the right time
When a patient is ready to leave the hospital, post-acute providers need more than just a discharge order. They need a full picture of the patient’s condition — treatment history, medication details, mobility status and cognitive function.
The truth is that these data points aren’t just wellness indicators. They also help determine which post-acute provider would extend the best care for the patient. Unfortunately, this information often doesn’t make it where it needs to go — to care managers. When teams are forced to make decisions with an incomplete picture, delays and errors become inevitable.
Breaking through data silos
Hospitals and post-acute providers often operate in silos, contributing to a general lack of alignment and accountability. Without following shared workflows that enable coordination beyond organizational boundaries — from hospitals to payers — care management remains inefficient and often unreliable.
What’s needed is a bi-directional data flow, a system where information moves freely in real-time between stakeholders, keeping everyone on the same page. That means seeking agreement across care managers and their counterparts on all detailed steps and transparency to see the current status of patients, from identifying post-acute needs and available partners to obtaining prior authorizations and discharging patients.
Everyone knows that multiple steps, handoffs and clinical reviews must happen to achieve successful transitions of care. Also, because there's no standard for how these tasks should be properly conducted, customizations to address the specific needs of sending and receiving referrals are necessary with any software solutions designed to help.
Achieving this goal isn’t easy. It entails overhauling outdated processes and embracing modern interoperability. Electronic health records systems must talk to each other using APIs and Fast Healthcare Interoperability Resources (FHIR) standards. Automated data sharing should replace manual updates, communicating medication changes and lab results to post-acute teams instantly. Secure messaging channels should replace phone tag and email chains. And advanced digital platforms that make the best post-acute care easily identifiable should be a gold standard.
No matter the difficulty of this transformation, when data flows in real time, care managers can confidently assess the right post-acute options for their patients. Simultaneously, post-acute providers can anticipate patient needs, act faster, and reduce unnecessary complications and readmissions. Together, this helps create a more effective care ecosystem for all participants.
Smarter referrals lead to better care
Currently, many hospital discharge teams rely on outdated methods to refer patients, often defaulting to the nearest available facility instead of the best match. Implementing a data-driven referral marketplace changes that by enabling hospitals to connect patients with post-acute providers based on real-time data — factors like provider availability, clinical expertise and performance metrics.
This shift offers real benefits. When patients go to the right provider the first time, they recover faster and are less likely to be readmitted. It also streamlines hospital discharge workflows, eliminating time-consuming administrative hurdles. And for health systems and payers, it provides transparency into provider performance and patient outcomes, enabling them to make data-backed decisions about care networks and partnerships.
Real-world results of modern care management
The shift to modernized care management isn’t just theoretically beneficial — hospitals and health systems are already seeing results.
BayCare Health System provides a powerful example of how the right digital tools can improve post-acute transitions. Overseeing more than 67,000 discharges annually, BayCare’s care managers faced common challenges to conducting care transitions — fragmented workflows and inconsistent communication between hospitals and post-acute providers.
Authorizations that should have taken hours often dragged on for days, keeping patients in the hospital longer than necessary. This inefficiency certainly posed resource issues, but it also strained hospital capacity and delayed post-acute care.
Recognizing the challenge, BayCare’s team streamlined the process by investing in a digital platform built on a solid data foundation to automate administrative steps, standardize communication between hospitals and post-acute facilities, and roll out a badge-based system to recognize and reward high-performing, responsive, quality-focused post-acute providers.
Authorization times, which had previously stretched to four days in some cases, dropped to less than a day with select payers. Average patient lengths of stay for post-acute referrals was reduced by a full day, freeing up hospital capacity and ensuring patients received timely care in the right setting. The shift enhanced efficiency — it also directly improved the patient experience, reduced strain on staff and saved costs across the board.
The shift toward more post-acute care isn’t slowing down, nor are the challenges that come with it. Hospitals can’t afford to rely on outdated processes that leave patients and providers struggling to keep up.
Investing in digital tools that enable real-time data exchange and smarter referrals isn’t just an efficiency play — it’s a necessary step toward better patient outcomes and a more sustainable healthcare system.
Russell Graney is the founder and CEO of Aidin, a platform dedicated to simplifying care management and improving care transitions. Motivated by his uncle’s diagnosis of early-onset Alzheimer’s, Russell left private equity to create Aidin.