Healthcare & Interoperability
Lost in Transition: Addressing the Post-Acute Care Disconnect
Healthcare & InteroperabilityWhen the continuity of patient records breaks down between a hospital and a Skilled Nursing Facility (SNF), the consequences are severe: medical errors rise, readmission rates soar, and an already fragile system is strained by the hidden cost of uncompensated care. For patients, particularly those affected by a quickly evolving Medicare Advantage landscape, these transitions are fraught with confusion about coverage and authorization timelines, leading to fractured care paths.
During a recent Skilled Nursing News webinar, I spoke with other industry experts about the major pain points affecting SNFs today and how cost-effective, AI-driven workflow integrations can address them head-on.
The Rising Cost of Prior Authorization and Payer Delays
One of the most damaging pain points for SNFs centers on the prior authorization (PA) requirements imposed by Medicare Advantage plans. A recent article found MA beneficiaries experience a 3.1 percentage-point higher likelihood of hospital stays lasting 14 days or more while awaiting SNF placement, contributing to an estimated $5.5 billion in discharge delay costs for hospitals in 2023.
This leaves SNFs with a difficult choice: admit a patient before receiving PA approval and risk providing uncompensated services, or wait for approval and contribute to longer, unnecessary hospital stays. This hesitation is understandable, as facilities face both financial risk and the ethical dilemma of informing residents they may have to self-pay for care.
“The facility is not going to take, or is going to be very hesitant, about taking a patient prior to that prior auth being delivered for two reasons. First of all, it’s not fair to the resident to take them and then find out, oops, they have to pay for their stay. Right. And then secondly, obviously the facility would like to get paid.”
– Michelle Stuercke, Chief Clinical Officer, TCM Consulting & Management
To mitigate this, some facilities have adopted a proactive stance. Michelle Stuercke, Chief Clinical Officer at TCM Management & Consulting, shared her team’s approach: “The minute we have an inkling that we may be getting the patient… we start that prior auth right away.”
While CMS is mandating faster decision times—72 hours for urgent and seven days for standard authorizations starting January 1, 2027—many feel these timelines are still too slow. As I noted, even 72 hours is too long for a patient who no longer needs to be in an expensive hospital bed.
Drowning in Documents: The Unstructured Data Problem
Picture it now: an 82-year-old recovering from a hip fracture arrives at a SNF with a deluge of documents—discharge summaries, medication lists, and reports totaling hundreds of pages, all in the form of scanned images or faxed PDFs. This is the reality of unstructured data in healthcare. Critical information is often inconsistent, outdated, or buried, forcing staff into what feels like documentation archaeology. This burden is immense.
As I shared, approximately 50% of all documents in healthcare are unstructured, and when including images, that figure climbs to 80% of all clinical content. If you have a 100-page PDF document, somebody, some human, has to look at it. You have to be able to digest that information the right way so that it can be consumed on the receiving end. When clinical information arrives in a standardized, machine-readable format, it can be ingested directly into the facility’s EHR, allowing staff to focus on patient care instead of manual data entry.
Medication Reconciliation: A Critical Information Gap
Medication reconciliation (MedRec) is a high-risk challenge driven by fragmented documentation. SNFs must immediately consolidate medication lists from multiple sources—the patient’s home regimen, the hospital’s summary, and incoming orders—which are often inconsistent.
Discrepancies can be dangerous. The failure to accurately capture and reconcile prescription and over-the-counter medications at every handoff—admission, transfer, and discharge—significantly increases the risk of adverse drug events, symptom exacerbation, and subsequent readmission. One recent study revealed roughly 16% of hospital readmissions are medication-related, of which 40% are potentially preventable.
Stuercke recalled a patient who was ordered both Plavix and Eliquis, a rare combination that poses a high risk. “Luckily,” she said, “through our med rec and our pharmacist, we caught it. But you always have to think, what if this resident would have gone home and taken those two meds together?“
Effective MedRec requires capturing everything, including OTC medications, and overcoming patient literacy or language barriers. Relying on a patient or caregiver to recall complex regimens is an unreliable and error-prone workflow. Getting this information into a structured data format is essential for reducing risk.
The Path to Interoperability: From Fax to FHIR
The federal government is pushing for greater interoperability through frameworks like the Trusted Exchange Framework and Common Agreement (TEFCA) and Qualified Health Information Networks (QHINs). These initiatives aim to create a “network of networks,” enabling secure, bidirectional data queries for treatment purposes, much like how mobile phone networks seamlessly hand off signals between towers.
These frameworks rely on standards like Fast Healthcare Interoperability Resources (FHIR) to structure data for exchange. However, many SNFs, particularly those in underserved communities, lack the resources to implement these complex technologies. This creates a disparity where not all providers can access the same patient data, hindering the goal of equitable care.
For resource-constrained facilities, digital cloud faxing supported by intelligent data extraction offers a pragmatic, cost-effective, and immediate solution. This approach builds a bridge between today’s fax-dependent reality and tomorrow’s fully interoperable ecosystem.
AI layers, including Machine Learning and Natural Language Processing (NLP), can automatically read, classify, and extract key data points from unstructured faxes and PDFs, including handwritten notes. From there, the structured data can be transformed into a FHIR message and mapped directly into an EHR or FHIR-enabled center. This “Fax-to-FHIR” solution allows health systems and care settings to achieve interoperability without disrupting their existing, critical fax processes.
This technology directly tackles the documentation and MedRec challenges. By instantly extracting and cross-referencing medication lists from multiple faxed sources, SNFs can significantly reduce manual data entry and error rates. The solution requires minimal upfront investment and allows facilities to modernize workflows without a costly and complex EHR overhaul.
Preparing for the Horizon: Policy Shifts and Discharge Readiness
Looking ahead, SNFs face a landscape shaped by tightening regulations and financial pressures. Medicaid cutbacks are expected to increase the burden of uncompensated care, while stricter MA oversight will intensify scrutiny of care delivery. Payers may begin closely reviewing certain ICD-10 diagnosis codes to combat waste, adding another layer of administrative complexity.
Additionally, regulations now mandate that SNFs ensure patients are discharged into a safe environment. This requires crystal-clear documentation and effective patient education, especially for those returning home.
As Carrie Kneisley, Director of Health Care Admissions at Garden Spot Communities, stated, transitions are complex. “It’s not just a simple thing. It’s more like, how can we meet their needs and what’s best for the resident? And it’s financial, it’s medical, it’s mood, it’s cognitive.“
What to Do Next: An Actionable Checklist for SNFs
- Develop a Proactive Prior Authorization Playbook: Begin the PA process as soon as a potential admission is identified. Don’t wait for the hospital to initiate.
- Standardize Your Medication Reconciliation Protocol: Implement a multi-source verification process for MedRec at every handoff—admission, transfer, and discharge. Include OTC medications and supplements in your review.
- Explore AI-Enabled Data Extraction: Assess solutions that use AI, OCR, and NLP to extract structured data from inbound faxes. This can automate data entry and accelerate admission readiness.
- Simplify Discharge Education: Create discharge instructions in plain language, accounting for health literacy and language barriers. Ensure patients and caregivers understand the plan of care before they leave.
- Enable Data Query Capabilities: Work with your EHR vendor to activate query functions through networks like Carequality or an emerging QHIN to gain on-demand access to patient histories.
By embracing practical technologies and refining key workflows, SNFs can navigate the intricacies of care transitions, reduce administrative friction, and ultimately enhance patient safety and outcomes.
Next Steps: Deep Dive into the Discussion
The challenges of prior authorization, documentation, and medication reconciliation are complex, but the solutions are actionable. To hear the panelists’ complete strategies for implementing modern, cost-effective workflow solutions—including further details on navigating policy shifts and leveraging AI for data extraction—watch the full Skilled Nursing News webinar.
