Enhancing Transitions of Care (TOC) for Long-Term Post Acute Care (LTPAC) Through Health IT Innovation

Authors: Rose Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA, FAHIMA, First Class Solutions, Inc; Marianne Outzen, MS, OTR/L, MBI, CHPM, St. Luke’s Health System, Idaho; Slyvia Rowe, MSN, RN, NI-BC, CPHIMS, CHPC, Ethica; Kim Suda,MBA, BSN, RN, CNRN, Helion

Executive Summary

Transitions of care (TOC) are pivotal moments that impact patient safety, cost, and outcomes —especially in long-term and post-acute care (LTPAC). Yet, the technology infrastructure that supports these transitions remains underdeveloped. Fragmented data systems, lack of real-time communication, and underuse of interoperable platforms can contribute to adverse events, readmissions, and missed care opportunities. To improve these transitions, the industry must continue advancing toward more connected and patient-centered solutions. Health IT leaders are positioned to solve these issues through strategic design, integration, and collaboration.

Current Challenges in LTPAC Transitions of Care

Limited Interoperability in LTPAC

Many LTPAC facilities operate with limited financial and staffing resources and rely on EHRs that can widely vary in terms of functionality and certification status. This creates barriers to accurate, real-time communication and impedes meaningful data sharing with hospitals, post-acute providers (skilled nursing facility (SNFs), home health care agencies (HHAs), inpatient rehab facilities (IRFs), long term acute care hospitals (LTACHs), physician practices, pharmacies and other healthcare providers.

Inconsistent Data Standards and Messaging Protocols

Disparate use of Health Level 7 (HL7) Consolidated Clinical Document Architecture (C-CDA), Fast Healthcare Interoperability Resources (FHIR), and DirectTrust messaging limits cross-platform communication and makes automated care coordination difficult. Many providers still rely on faxing, and even when digital formats are used, documents like PDFs are often not easily ingestible by receiving systems. These variations in format present challenges during transitions. 

Fragmented Participation in Health Information Exchanges (HIEs)

LTPAC providers often face barriers to participating in regional HIEs (such as costs to connect to HIEs, ongoing transaction fees, limited internal IT expertise needed to implement and maintain HIE connections, etc.), leaving gaps in the longitudinal patient record and delaying access to post-discharge data.

Delayed and Incomplete Discharge Information

Policies and workflows at the discharging facility often result in crucial information such as medication reconciliation, care plans, relevant exams, and functional status assessments failing to reach providers in time. This can result in adverse events such as hospitalizations or medication errors as well as extended stays in the LTPAC setting. This is not only a problem between acute and post-acute providers (i.e., acute to post-acute or vice versa) but also when patients transfer between LTPAC providers (i.e., SNF to HHA transfers or SNF to SNF transfers).

Insufficient Tools for Patient and Caregiver Engagement

Digital tools such as portals, reminders, and mobile-friendly discharge instructions are underutilized, creating confusion and low adherence in the home or post-acute setting.

Technology-Based Recommendations for TOC Improvement

Invest in Interoperable Health IT

Expand EHR integration and HIE participation for LTPAC providers. Federal agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary for Technology Policy (ASTP) should incentivize EHR certification and enforce data-sharing compliance to ensure LTPAC is meaningfully included in national interoperability efforts.

• Promote funding mechanisms or grants to upgrade LTPAC EHR systems.
• Encourage HIE onboarding by subsidizing infrastructure and training.
• Align these efforts with Trusted Exchange Framework and Common Agreement (TEFCA) and United States Core Data for Interoperability (USCDI) implementation.

Advance Interoperability Across Care Settings

• Standardize the use of FHIR-enabled Application Programming Interfaces (APIs) and Direct messaging for transitions documentation.
• Support bidirectional information flow between hospitals and LTPACs through national exchange frameworks.

Embed TOC Workflows into Clinical Systems

• Integrate standardized templates for discharge summaries, medication lists, and risk stratification into EHR systems.
• Use AI and predictive analytics to automate identification of high-risk transitions and prioritize follow-up interventions.

Enable Analytics to Monitor and Improve TOC

• Develop real-time dashboards that track TOC metrics, including, but not limited to, 30-day readmissions, timely completion and sharing of discharge information from discharging provider, follow-up appointment adherence, and the timeliness of TOCs for such transitions as the first home health visit after discharge from a SNF and the negative impact of a delayed start of care.
• Use aggregated data to identify trends and inform system-wide improvement strategies.

Enhance Patient and Caregiver-Facing Technologies

• Build or integrate digital tools such as apps and portals to deliver personalized discharge instructions, symptom tracking, and communication tools.
• Incorporate patient-reported outcomes (PROs) to monitor recovery and flag complications early.

Value-Based Care as a Driver?

The new CMS TEAMs (Transforming Episode Accountability Model) payment model and emphasis on Accountable Care Organizations (ACOs) present both challenges and strategic opportunities for health IT leaders in acute care to collaborate with and support the LTPAC providers in their region. By holding acute and post-acute providers jointly accountable for cost and quality across care episodes, these models heighten the demand for robust interoperability, real-time data exchange, and advanced analytics. This emphasis is also present in the payer space (e.g. Medicare Advantage, Medicaid, and commercial plans).

LTPAC organizations will need to enhance their health IT infrastructure to support seamless coordination with hospitals, physician groups, and other LTPACs to ensure compliance with reporting requirements, and monitor performance metrics tied to reimbursement. This includes leveraging technologies such as EHR systems with strong interoperability capabilities, predictive analytics platforms for readmission risk scoring, and secure care coordination tools integrated with Admission-Discharge-Transfer (ADT) feeds.

From a vendor strategy perspective, partnering with providers of longitudinal care management platforms and integrating with HIEs can support participation in preferred networks. Additionally, adopting FHIR-enabled APIs and aligning with TEFCA standards will be key to enabling bidirectional data exchange.

These models accelerate the move toward digitally integrated, value-based ecosystems, making health IT a central driver of both financial performance and clinical excellence in the LTPAC sector.

Conclusion

Breakdowns in TOC are often rooted in inadequate or siloed technology. Bridging the digital divide between acute care and LTPAC settings is essential for improving patient outcomes and advancing value-based care. To support this effort, financial incentives and technical assistance from government agencies will be critical in helping LTPAC organizations enhance their technology platforms. Additionally, with targeted investments in interoperable infrastructure, smarter EHR design, and inclusive data sharing strategies across the care continuum, the health IT community can ensure safer, more coordinated, and more efficient transitions for patients.