Beyond the Visit: Why Care Coordination Is Becoming Essential in Post-Acute Care

Caring for high-risk patients does not end when they leave a hospital, skilled nursing facility, or post-acute practice. In many cases, that is when the most vulnerable phase of care begins. 

Patients may return home with new medications, multiple chronic conditions, follow-up appointments, monitoring instructions, and services that still need to be coordinated. At the same time, post-acute organizations are being asked to manage increasingly complex populations with fewer resources and greater accountability for what happens after discharge. 

During the recent webinar, Beyond the Visit: Managing High-Risk Patients Across the Acute-to-Post-Acute Continuum, CareHarmony partnered with Netsmart GEHRIMED to explore how post-acute providers can better support high-risk patients after discharge. The session was led by CareHarmony CEO and co-founder Gokul Mohan and introduced by Beth Reece, Vice President and General Manager at Netsmart.  

The central message was straightforward: delivering strong care during the encounter is no longer enough. The real differentiator is how well organizations coordinate care after the visit. 

Post-Acute Providers Are Managing More Complexity With Less Capacity 

The pressure on post-acute care continues to grow. 

According to the Medicare Payment Advisory Commission (MedPAC), the number of Medicare-participating skilled nursing facilities declined from 15,297 in 2019 to 14,518 in 2025, a reduction of 779 facilities. Data from the National Center for Health Statistics show that 62% of residential care community residents require assistance with three or more activities of daily living, while the U.S. Bureau of Labor Statistics reports that employment in skilled nursing facilities remains 7.3% below pre-pandemic levels. 

Taken together, those figures illustrate the challenge facing the sector: fewer facilities, more complex patients, and less workforce capacity to support them. 

Accountability for outcomes is also expanding. According to the Centers for Medicare & Medicaid Services (CMS), beginning in fiscal year 2027, eight quality measures will influence the Skilled Nursing Facility Value-Based Purchasing Program. 

Post-acute organizations are therefore being asked to influence not only what happens during a facility stay, but also what happens after the patient leaves. 

Readmissions Remain a Persistent Problem 

Despite years of attention, readmissions have not meaningfully improved. 

According to MedPAC, risk-adjusted all-cause 30-day hospital readmissions among fee-for-service Medicare beneficiaries reached a low of 14.6% in 2022 before rising to 15.1% in 2023 and 15.4% in 2024. Across skilled nursing facilities, the median potentially preventable readmission rate was 10.7%, or roughly one in every ten stays. 

CMS’s Skilled Nursing Facility 30-Day All-Cause Readmission Measure Annual Update Report found that patients entering post-acute care are more likely to have conditions associated with rehospitalization, including: 

• 38.9% had congestive heart failure.  

• 38.2% had specified heart arrhythmias.  

• 30.8% had diabetes with complications.  

• 27% had chronic ischemic heart disease.  

• 24.3% had COPD.  

Patients carried an average of 1.6 of those five conditions, and the population had a 20.3% all-cause unplanned readmission rate within 30 days.  

These patients rarely have a single, isolated need. They may require medication support, symptom monitoring, caregiver education, follow-up with multiple providers, and help addressing nonclinical barriers. 

Much of that work happens after discharge. 

The Most Important Gaps Often Appear Between Encounters 

Once a patient leaves a facility, responsibility can become fragmented quickly. 

A medication list may change during the hospital stay. A follow-up appointment may not be scheduled. A home health referral may be delayed. A caregiver may not know which symptoms require immediate attention. Transportation, food insecurity, or confusion about the care plan may prevent the patient from following through. 

These problems do not necessarily reflect poor clinical care. More often, they reflect a lack of continuity. 

Clinical teams may not know a patient is struggling until the next appointment, emergency department visit, or hospitalization. By then, the opportunity for early intervention may have passed. 

That is why discharge should not be viewed as the end of care. It should mark the beginning of the next phase. 

Closing the Gap Requires Consistent, Repeatable Work 

Effective care transitions are not built around a single follow-up call. They depend on repeatable interventions that help care teams maintain visibility and respond when a patient’s condition begins to change. 

The webinar identified six core activities: 

• Medication reconciliation: Reviewing medication lists after discharge and as additional providers become involved.  

• Vital-sign monitoring: Tracking measures like weight, blood pressure, and glucose to identify early signs of deterioration.  

• Ancillary coordination: Helping patients arrange home health, therapy, durable medical equipment, and other services.  

• Social needs screening: Identifying transportation, food insecurity, caregiver availability, and other barriers that can affect adherence.  

• Caregiver activation: Equipping caregivers with the education and support they need.  

• Escalation pathways: Establishing clear processes for connecting patients with the appropriate clinician when conditions worsen.  

None of these interventions are new. The challenge is delivering them consistently across an entire patient population. 

Structured Coordination Can Reduce Readmissions 

The evidence presented during the webinar suggests that structured transitional care can make a measurable difference. 

A study published in the Journal of Hospital Medicine by Rosen and colleagues compared usual care with a coordinated transitional care program that included clinical oversight, medication management, and team support. The 30-day readmission rate was 23% under usual care and 17.2% under coordinated care. The intervention was associated with 29% lower adjusted odds of 30-day hospital readmission.  

The takeaway is not that one technology platform or one outreach attempt prevents readmissions. Better outcomes come from a reliable system that helps teams identify risk, prioritize outreach, resolve barriers, and escalate concerns before they become emergencies. 

Technology supports that work by organizing information, helping teams focus on the right patients, and making follow-up more consistent. The value comes from how clinicians, care coordinators, patients, and caregivers use that information. 

Coordination Is Becoming Part of the Competitive Landscape 

The need for stronger care coordination is also reshaping the post-acute landscape.  

Healthcare organizations, technology companies, and investors are increasingly focusing on solutions that support longitudinal care, improve transitions, and help providers succeed under value-based reimbursement models. 

For independent post-acute practices, this creates both pressure and opportunity. 

Strong rounding and high-quality care during the encounter remain essential, but they may no longer be enough to distinguish one organization from another. Providers that can maintain visibility after discharge, coordinate across settings, and help reduce avoidable utilization may be better positioned to strengthen relationships with facilities, hospitals, patients, and referral partners. 

Care Coordination Can Be a Practical First Step Toward Value-Based Care 

Not every organization is ready to participate in an accountable care organization, accept downside risk, or operate under full capitation. 

Care coordination can provide a more accessible starting point. 

The webinar outlined a progression many organizations follow: 

• Care coordination establishes recurring patient engagement and monthly reimbursement without downside risk.  

• ACO participation creates opportunities to share in savings as avoidable utilization declines.  

• Full capitation rewards organizations that successfully manage total cost of care.  

This progression allows organizations to develop the operational capabilities required for value-based care before taking on more advanced financial risk. 

The shift is already underway. According to CMS, 2% of Medicare Part A payments under the Skilled Nursing Facility Value-Based Purchasing Program are already tied to performance. 

CMS Has Been Building Toward Longitudinal Care for Years 

The movement toward care between visits is not new. 

Over the past decade, CMS has steadily expanded reimbursement for longitudinal care: 

• 2015: Chronic Care Management (CCM)  

• 2017: Complex Chronic Care Management  

• 2019: Remote Patient Monitoring (RPM)  

• 2020: Principal Care Management (PCM)  

• 2022: Increased CCM reimbursement  

• 2025: Advanced Primary Care Management (APCM)  

• 2026: ACCESS Model  

Taken together, these programs demonstrate a broader shift toward recognizing the work required to support patients between traditional clinical encounters. 

Choosing the Right Care Management Model 

There is no single care management program that fits every patient population. 

• Chronic Care Management (CCM) supports patients with two or more chronic conditions.  

• Principal Care Management (PCM) focuses on patients whose care is driven by one serious chronic condition.  

• Advanced Primary Care Management (APCM) supports comprehensive primary care with a broader, longitudinal approach.  

• Remote Patient Monitoring (RPM) adds physiologic monitoring for appropriate patient populations.  

• The ACCESS Model introduces another pathway for eligible patients with cardio-kidney-metabolic, musculoskeletal, and behavioral health conditions.  

The objective isn’t simply to choose a reimbursable program. It’s to match the right care model to the right patient population while ensuring the organization has the infrastructure to deliver it consistently. 

Scaling Care Coordination Requires More Than Outreach 

Successful care management programs rely on more than care coordinators alone. 

The webinar identified six foundational capabilities: 

• Enrollment  

• Care coordination  

• Clinical escalation  

• Billing and compliance  

• Technology integration  

• Analytics and reporting  

These functions work together. Without risk stratification, teams may focus on the wrong patients. Without efficient workflows and billing processes, organizations may struggle to sustain the program. And without sufficient enrollment, even well-designed programs may never reach scale. 

Research by Agarwal, Barnett, Souza, and Landon found that only 3.4% of eligible Medicare beneficiaries received Chronic Care Management in 2019, highlighting the operational challenges many organizations continue to face. 

Looking Beyond the Visit 

Discharge shouldn’t mark the end of care, it should mark the beginning of a more coordinated phase of the patient journey. 

Healthcare organizations that invest in scalable care coordination will be better positioned to improve outcomes, strengthen clinical relationships, and adapt as reimbursement continues shifting toward longitudinal, value-based care. 

At CareHarmony, that’s exactly what we help organizations do. Through experienced care coordinators, evidence-based workflows, and technology-enabled engagement, we help providers extend care beyond the visit while supporting better patient outcomes and long-term success. 

Sources:  

• Agarwal SD, Barnett ML, Souza J, Landon BE. Use of Chronic Care Management Among Medicare Beneficiaries, 2015–2019.  

• Centers for Medicare & Medicaid Services. Measures: Skilled Nursing Facility Value-Based Purchasing Program.  

• Centers for Medicare & Medicaid Services. Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) Annual Update Report.  

• Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare Payment Policy. March 2026.  

• Medicare Payment Advisory Commission. MedPAC Data Book. July 2026.  

• Melekin A, et al. Residential Care Community Resident Characteristics: United States, 2022. National Center for Health Statistics, 2024.  

• Rosen BT, et al. The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities. Journal of Hospital Medicine. 2018.  

• U.S. Bureau of Labor Statistics. Home- and Community-Based Care versus Institution-Based Care. 2024.