Value-based care is changing how hospitals are measured. Under the Transforming Episode Accountability Model (TEAM) from the Centers for Medicare and Medicaid Services (CMS), accountability for cost and quality extends past discharge. Much of that window plays out in a skilled nursing facility (SNF), where hospital visibility usually stops. One in four Medicare patients discharged to a SNF returns to the hospital within 30 days.

This session follows the patient through three moments where information breaks down: the handoff from hospital to SNF, the stay itself, and the transfer from the SNF to the emergency department (ED). Each moment creates work and risk for hospital and SNF teams alike. You will see how hospital and accountable care organization (ACO) teams track what is happening during the stay and spot readmission risk earlier. You will also see how SNF documentation gives ED clinicians a fuller picture before they decide whether to admit.

A panel of acute and post-acute leaders will discuss what they watch, when they act, and how they built this into daily practice. PointClickCare will then review the solutions that support this work, followed by audience questions.

Whether you lead a hospital, manage care transitions, or own post-acute strategy, you will leave with ideas you can apply across your SNF network.

Learning Objectives

• Understand how episode-based payment models extend hospital accountability into the post-acute stay.
• Explore how post-acute visibility helps hospital teams track patients and identify readmission risk earlier.
• Learn how clinical documentation in the SNF shapes what hospitals see during the stay and what the ED knows at transfer.
• Identify practical steps for strengthening collaboration across your SNF network.