Managing patient health doesn’t end when the patient leaves the hospital. In fact, that’s when some of the most critical and cost-sensitive care decisions begin. Post-acute care is a pivotal factor for Accountable Care Organizations in the recovery of their patients and the management of avoidable readmissions. It’s also a major lever in total cost of care and overall performance against value-based benchmarks.
But for many ACOs, post-acute care remains an under-managed frontier. Patients are discharged into a maze of skilled nursing facilities, home health agencies, rehabilitation centers and other services. Without deliberate coordination, those referrals can become a blind spot that undermines clinical and financial performance.
Positioning post-acute care as a strategic priority is critical to value-based care success. Visibility into the patient journey, provider performance and the impact of care, quality and patient experience must be accessible to support the success of this initiative.
The Shift in Accountability
Regulatory models have pushed hospitals to extend responsibility beyond inpatient stays. Early initiatives such as the Bundled Payments for Care Improvement and the Comprehensive Care for Joint Replacement program serve as past examples of how CMS ties hospital performance to what happens after discharge.
Those models have evolved – and continue to do so. The upcoming Transforming Episode Accountability Model (TEAM), scheduled to begin in 2026, builds on lessons for earlier programs while broadening the overall scope. TEAM holds hospitals accountable for the cost and quality of care across the entire episode, from surgery through recovery. It emphasizes coordination across settings, health equity and long-term patient outcomes.
This evolution signals a permanent change in expectations: hospital accountability does not stop at the hospital doors. For ACOs, this creates a natural point of alignment. While incentives may not be identical, hospitals and ACOs share a vested interest in smooth transitions, fewer readmissions and appropriate care delivered in the right setting at the right time.
Passive oversight to active coordination
Decisions about the path of the patient after discharge happen quickly, often with limited input from the ACO’s network physicians. Discharge planners may default to familiar providers or those with immediate availability. Patients and families, when given a choice, often select based on proximity rather than performance.
Uncoordinated processes like these can lead to wide variation in cost and quality. One skilled nursing facility (SNF) may excel in functional recovery and low readmissions, while another several miles away consistently underperforms. Without visibility and influence, ACOs inherit the clinical and financial downstream impact of those choices.
Active coordination begins with mapping the post-acute care landscape. Which SNFs, rehabilitation centers and home health agencies receive your attributed patients? How do they perform on key quality and utilization measures? Are there identifiable patterns in readmissions, length of stay or per-episode costs? How do these compare to regional benchmarks?
Clear, actionable information allows ACOs to guide referrals toward the highest-performing partners and collaborate with others on targeted improvements.
Strategic post-acute networks
Not all recently hospitalized patients require post-acute services. However, for those who do, the outcome can be make-or-break. Poorly matched placements can result in unnecessary utilization, higher costs and avoidable readmissions.
High-performing ACOs treat post-acute partnerships as a core component of their network strategy. This means:
- Evaluating quality: Readmission rates, functional status improvements, patient satisfaction and regulatory compliance
- Assessing cost efficiencies: Average length of stay, cost per episode and alignment with value-based payment models
- Aligning care coordination: Ensuring seamless information exchange between post-acute providers and referring physicians
- Embedding accountability: Setting performance expectations and regularly reviewing results
Building these networks requires relationship-building and robust analytics. Relationships foster trust and collaboration. Analytics ensure collaboration is grounded in measurable outcomes.
The bridge between organizations
Hospitals and ACOs often use different terms, but the goals are aligned. For ACOs, the aim is to reduce total cost of care while improving patient outcomes. For hospitals, it’s smoother transitions, fewer readmissions and meeting bundled payment or episode-based targets.
Data is the bridge that connects these objectives. ACOs that clearly demonstrate post-acute care utilization patterns, cost variability and quality performance can quickly establish themselves as a valuable partner in post-discharge planning.
For example, claims data can reveal that certain SNFs significantly lower readmission rates or that some home health agencies achieve comparable outcomes in fewer visits. ACOs that share these insights benefit both organizations. Over time, this exchange builds trust and creates a foundation for joint performance improvement.
Physicians and post-acute success
Although much of the referral process happens within the hospital, ACO physicians and care teams have a central role to ensure successful transitions. The days and weeks after discharge are high risk for complications, medication errors and care gaps. Prompt follow-up and active care management can mean the difference between recovery and readmission.
Practices within Accountable Care Organizations can support post-acute success by:
- Prioritizing follow-up appointments within the first week post-discharge
- Communicating directly with post-acute providers about care plans and progress
- Monitoring patient status and intervening quickly when issues arise
- Using care coordinators to close gaps and maintain continuity.
These actions serve to improve patient outcomes while directly impacting utilization metrics and financial performance under value-based arrangements.
Action influenced by data intelligence
Identifying high-performing post-acute providers is the first step. To capture value, data intelligence must translate into deliberate action:
- Preferred provider networks: Establish a list of vetted post-acute partners with strong performance records and encourage consistent referrals among all providers and partners
- Performance feedback: Share comparative data across the organization and with partners to highlight strengths, address opportunities for improvement and provide accountability
- Collaborative care pathways: Create standard protocols for common conditions, ensuring consistent care across providers
- Continuous monitoring: Track performance over time and adjust partnerships as circumstances change
This process is ongoing. Post-acute care markets shift and performance can fluctuate with changes in staffing, leadership or patient populations. A sustained commitment to using data to drive action ensures ongoing monitoring and collaboration that maintains a high-performing network.
A shared responsibility for value
Value-based care has redefined the boundaries of accountability. Hospitals, physicians and ACOs are now held accountable for outcomes beyond their immediate setting.
For ACOs, the challenge is to build the visibility, relationships and processes necessary to influence care outside the organization and their members’ control. ACOs must bridge care settings, align incentives and drive better results for patients and for providers.
Strong post-acute care partnerships aren’t optional. They’re essential to achieve success in value-based care. By embracing this responsibility, ACOs can position themselves as leaders in shaping a more coordinated, efficient and patient-centered future.
