The Data Needed for Transitions to Post-Acute Care

A large number of hospitalizations end with discharges to nursing homes, rehabilitation facilities, and other types of post-acute care. Some patients are aware they will require post-acute care before something such as a hip replacement, while others are rushed to the ER and no one has time to think of post-acute care until discharge is near.

In all cases, finding the right facility that offers the services needed by the patient requires a thorough and sophisticated understanding of the patient, including both their baseline condition and the special demands of their current hospitalization. With the rise of COVID-19, which leaves many victims with a variety of long-term weaknesses and organ damage, sophisticated post-acute care is even more in demand.

I talked recently to Lissy Hu, MD, MBA, who is co-founder and CEO of CarePort Health. As a care coordination platform providing data and services across the patient journey–from hospital admission to post-acute discharge–CarePort’s solution is used in one-third of all hospital discharges in the U.S. Used by more than 110,000 post-acute providers and 1,000 hospitals across 43 states, the company clearly needs efficient processes and unfettered access to data about both the patient and the post-acute facility.

Some issues that determine placement focus on the patient. For example, what conditions does the patient have, and does she need special treatment in the facility, such as dialysis? Does she have special rooming needs, such as a private room? These requirements must be matched up with data about the facility to ensure that proper services, like dialysis, can be provided.

The coronavirus has also made the placement of patients in need of post-acute care even more challenging. In many cases, facilities require patients to be “COVID-19 free,” a vague criterion that can vary from one jurisdiction or facility to another. For instance, does the facility require one negative test or two? What if one test result is positive and the other negative?

Insurance is also an important factor, to make sure the facility is covered in the patient’s network. Thus, the patient’s billing and insurance information must be available to CarePort Health. And the company has to know basic resource matters, such as which facilities have openings on the day of discharge.

A central component of CarePort Health’s success therefore depends on pulling data automatically from EHRs. None of this is done manually, but automation is a challenge. Electronic records are often incompatible, even between different departments of a single hospital. The wave of purchases and mergers over the past decade have allowed some institutions to standardize on a single electronic record system, but many hospitals have been unable to achieve that long after consolidation.

Many systems have idiosyncratic data fields. If you see a discharge code of 3, for instance, it can mean whatever the IT team at a specific hospital decided it would mean.

A service like post-acute care transfer increases in value by having coverage as large as possible: assuming facilities are of the same quality, a choice between 20 facilities allows better patient placements than a choice between 10. CarePort Health’s success is based on an immense investment in hooking into electronic systems, allowing disparate providers to better track and manage patients across the care continuum.

I can imagine a seamless data exchange network that makes the choice of placements so easy it can be done directly between the hospital and the post-acute facility. But this is not the world of records we have today, so we can be thankful for the exchange of information that takes place in the CarePort Health platform.

This article is part of the #HealthIT100in100

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About the author

Andy Oram

Andy Oram

Andy Oram writes and edits documents about many aspects of computing, ranging in size from blog postings to full-length books. Topics cover a wide range of computer technologies: data science and machine learning, programming languages, Web performance, Internet of Things, databases, free and open source software, and more. My editorial output at O'Reilly Media included the first books ever published commercially in the United States on Linux, the 2001 title Peer-to-Peer (frequently cited in connection with those technologies), and the 2007 title Beautiful Code. He is a regular correspondent on health IT and health policy for He also contributes to other publications about policy issues related to the Internet and about trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business.