Escaping the Black Hole: Why Post-Acute Blind Spots Are Hospitals’ Biggest Value-Based Risk

By Steve Holt, VP Government Affairs, PointClickCare

When the Centers for Medicare & Medicaid Services (CMS) launched the Transforming Episode Accountability Model (TEAM) and the AIM for Health Equity and Accountable Care Growth (AHEAD) model, they didn’t just tweak reimbursement—they shifted accountability beyond hospital walls. Suddenly, every preventable fall in a skilled nursing facility (SNF) and every missed medication at home boomerangs back as a financial hit. Yet many hospitals still discharge patients into what has become the post-acute “black hole”—a stretch of the care continuum where data disappear, communication breaks down, and quality is anyone’s guess. That void has grown into the most valuable variable in value-based care.

To keep up with these new rules, hospitals need more than discharge instructions and a faxed referral. They need visibility at the point of care, better coordination, and stronger ties that enable seamless transitions that improve outcomes. This isn’t about managing every detail across the continuum; it’s about closing the loop. The more hospitals can see and shape what happens after discharge, the better they’ll do in shared-risk models.

Optimizing Data Exchange Across Care Settings

Solving the black hole problem starts with moving the correct data to the right place at the right time. Clinical, social, and utilization information must flow seamlessly between hospitals, SNFs, home health agencies, and other community partners. Too often, information moves slowly—or not at all—leaving care teams in the dark.

This isn’t theoretical. Federal mandates, such as the IMPACT Act, require interoperable post-acute data exchange. Analysis by the Office of the Assistant Secretary for Planning and Evaluation confirms that gaps in these handoffs directly contribute to adverse events and avoidable readmissions. Despite these mandates, a technological gap exists, created by a lack of targeted funding that would allow SNFs to achieve interoperability goals.

Modern tools enable discharge planners to directly import structured medication lists into a SNF’s electronic health record (HER) and retrieve timely updates on vitals, therapy progress, and patient status, which are then reflected in hospital dashboards. When everyone shares a standard, current view of the patient, they can spot complications early and intervene before problems escalate.

Ensuring Safe and Complete Care Transitions

Data flow is only part of the equation. Transitions tend to fall apart when handoffs are rushed, incomplete, or unclear. A missing discharge summary, a missed follow-up, or a medication list that doesn’t line up can send a patient right back to the hospital.

Programs like the Care Transitions Intervention—used in the field for over 20 years—show that a few coordinated steps, such as walking through medications, educating the patient, and making a follow-up call, can reduce readmissions by nearly 30%.

Embedding transition checklists directly into the EHR helps ensure that physicians, case managers, and social workers complete their respective parts of the handoff before the patient exits the building.

Building High-Quality Post-Acute Partnerships

Hospitals can’t control every post-acute variable, but they can choose who they partner with—and how those relationships are set up. Building a preferred network of SNFs, home health agencies, and rehabilitation centers based on quality, not just convenience, is key.

The strongest networks run on clear expectations, shared goals, and regular communication. Setting joint benchmarks for readmissions, patient satisfaction, and documentation timeliness ensures that everyone is pulling in the same direction. Something as simple as routine check-ins with discharge networks can greatly impact patient outcomes for the better. Over time, these relationships foster a culture of mutual accountability that strengthens results.

Leveraging Predictive Analytics for Proactive Care

Predictive analytics can identify patients most likely to experience complications, enabling care teams to take preventive action—such as adjusting medications, coordinating physical therapy, or activating community supports—before an issue results in a readmission. But predictive tools only work if they’re actionable.

That means surfacing insights where they’ll be seen and used—during rounds, in huddles, and inside the workflows teams already rely on.

Empowering Care Teams Through Collaborative Decision Support

Actionable decision support should be integrated within the EHR, allowing clinicians to view risk scores, social needs, and care gaps when they need the information.

Collaboration tools need to be just as simple. Providers across hospital and post-acute settings should be able to message each other, share notes, and update care plans—without having to jump through hoops or switch between disconnected systems.

Establishing Feedback Loops for Continuous Improvement

Shared-risk success depends on shared visibility. Hospitals and their post-acute partners should track quality, outcomes, and cost performance against shared benchmarks and revisit those metrics frequently. Transparent data drive meaningful change. Sharing results across the network helps shine a light on what’s working, surface what needs attention, and build trust through shared accountability.

Seeing the Whole Journey

The post-acute black hole isn’t a given. Hospitals that build point-of-care visibility, form strong partnerships, and give their teams the right tools will be in the best position to succeed under TEAM, AHEAD, and other value-based care models.

This doesn’t have to be an overnight shift. It can start with one better handoff, one stronger data connection, or one clearer expectation. When hospitals stay focused on the whole care journey, they protect reimbursement, reduce avoidable harm, and deliver the kind of connected care patients deserve.