SNF Setback: Acute Care Providers Share Limited Data when Transferring Patients to Post-Acute Care

The following is a guest article by Sean Vandeweerd, Sr. Product Manager, PointClickCare Technologies Inc.

As patients move from acute-care facilities to skilled nursing facilities (SNFs), the sharing of critical patient information and associated data is extremely important for coordinating care. Despite best intentions, most acute-care providers are still not sharing all patient data and information.

In our 2019 Patient Transition Study, PointClickCare surveyed c-suite and other executives from acute and post-acute care facilities to better understand the types of technology used during transitions of care, as well as the challenges and opportunities that said technology present for providers to improve processes and care.

While the survey revealed transfer systems lacking in both provider settings, the results when looking at data transfers from hospitals to SNFs were particularly alarming: only 16 percent of acute-care providers reported sharing “all” patient data with their post-acute partners, 35 percent share “some,” and 7 percent share “very little.” While most provide critical data points such as medication information and demographic and diagnostic data, key elements such as measurements and observations, advanced care planning notes, and location and patient status information are largely missing.

About one-third of all readmissions happen within the first 72 hours, with the leading cause related to medication problems, such as transcription error. Most information sharing during patient transfers occurs via manual methods, such as paper or fax. As a result, post-acute care providers have to manually enter medication information from physical documents into their EHR.

PointClickCare’s research comes at a time when SNFs are preparing for CMS’s impending Patient-Driven Payment Model (PDPM) deadline in October, which will shift reimbursement to a value-based model. With an inability to coordinate data from acute care providers to their existing electronic health records, SNFs will be increasingly unable to deliver the type of care mandated by CMS, which is certain to negatively impact the opportunity for reimbursement and patient health outcomes.

According to one long-term post-acute care (LTPAC) CEO surveyed, a local hospital “uses faxes to accommodate HIPAA to be confidential,” forcing a manual method that stymies coordination. “Almost everything we touch is obtuse. You have to search it out, figure it out, and confirm it by phone,” adding that the absence of standardized forms and data-entry fields makes faxes especially inefficient.

A post-acute facility CEO, bemoaning the reliance on faxes, said, “When you get a 70-page fax and only four or five pages of it are relevant to anything, it’s a waste of time on both sides of the equation.” Another respondent noted coordination and follow-up are “done manually and by phone with copies of the patient chart.”

Patient privacy concerns about electronic data transfer are unfounded, and lead to transfer of less reliable information. For example, PointClickCare, the leading cloud-based software vendor for the acute and post-acute care markets, enables streamlining secure data exchange between all providers. PointClickCare partners can instantly locate patients within their care network, access patient timelines across the care continuum, view and filter data from care partners, and ensure patient data is being shared during transitions and beyond.

As one hospital executive noted, “With better communication between facilities, we would cut back on readmission and sending patients back to the ER and any sort of miscommunication.” In turn, this would mean better outcomes and reduced costs.

Electronic health data exchange also helps improve the transparency of data between acute care and skilled nursing facilities. This enables a stronger relationship and robust, population health capabilities that are scalable as the number of patients needing post-acute care continues to grow.

To download a copy of the study, visit our website.

About Sean Vandeweerd

Sean Vandeweerd is the Senior Product Manager for PointClickCare’s Integrated Care Management solution. In his role, he is responsible for leading a team tasked with establishing connections between PointClickCare’s Electronic Health Record (EHR) platform and various hospital and health systems. Learn more at

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