Navigating recovery with compassion and effective post-acute care models
For many patients, a hospital discharge isn’t the end of care; it’s the beginning of a critical healing phase. After a serious illness, surgery or injury, post-acute care can play a vital role in preventing complications, avoiding readmissions and restoring function. Whether delivered through skilled nursing facilities (SNFs), inpatient rehabilitation, long-term acute care or even at home, effective post-acute care can mean the difference between full recovery and long-term decline.
Yet, too often, post-acute care falls short. For example, 12% of hospitalized Medicare patients end up being readmitted for an avoidable reason. Readmissions are physically and mentally draining for patients, and expensive, both for the individual and the health care system.
With more than 40% of Medicare beneficiaries receiving some form of post-acute care after discharge—and with an aging population and rising rates of chronic disease—the need for consistent, effective, coordinated care beyond the hospital is more urgent than ever.
Current challenges in post-acute care
Today’s post-acute care landscape presents real challenges for providers and patients alike.
One major concern is our aging population. By 65, more than 90% of people will have at least one chronic condition, which can complicate recovery following a hospital stay. With the number of older Americans expected to increase dramatically in the coming years, the demand on already limited resources will only intensify.
At the same time, driven by a desire for greater independence and a return to normalcy, patients increasingly choose to recover at home. Surveys show a strong preference for high-quality home-based care following a hospital stay. However, for those facing caregiver constraints and socioeconomic hardships, this preference requires targeted support and resources.
Despite the growing demand for home-based recovery and the clinical benefits of coordinated care after a hospital discharge, too many patients still fall through the cracks. The most common breakdowns in the post-acute care process include:
- Limited post-discharge clinical engagement: Many patients who return to the hospital within 30 days never had a follow-up appointment with their care team.
- Missing critical post-discharge services: Without essential continuing care, including medication oversight, therapy or in-home support, conditions can deteriorate.
- Medication errors and confusion: Patients may take incorrect doses, skip medications or misunderstand instructions, leading to complications.
- Fragmented communication across care teams: Inadequate information sharing among providers can create dangerous gaps in care coordination.
- Insufficient preparation: Many patients and their caregivers don't understand essential details of the diagnosis, treatment plan or how to manage recovery at home, causing them to overlook or misuse critical elements of the care plan.
- Socioeconomic barriers to care adherence: Housing instability, financial constraints and food insecurity can prevent patients from following care plans.
What makes effective post-acute care?
Effective post-acute care requires a coordinated, multidisciplinary effort to support the patient, no matter where that care is delivered.
At the center of this model are the nurse case managers, who balance clinical precision with compassionate, patient-centered support. They check in regularly, monitor symptoms, ensure medication adherence and identify red flags before they escalate.
Comprehensive care management led by a nurse manager typically includes:
- Primary care and specialist follow-up
- Individualized risk assessments
- Medication reconciliation
- Caregiver education and support
- Regular RN outreach and patient health surveys
- Social worker involvement to address discharge barriers
When nurse case managers are enabled to engage closely with SNFs, home health agencies, primary care physicians and social services, they can anticipate and manage transitions proactively, preventing gaps in care, reducing readmissions and improving patient outcomes.
How an integrated, coordinated team elevates post-acute care
Well-designed post-acute care programs empower providers to deliver the best care, and patients to achieve their best outcomes. These programs focus on supporting quality patient recovery and reducing readmissions through an approach that includes:
- Alignment with evidence-based guidelines to ensure patients receive the appropriate level of care and length of stay for optimal outcomes, including specialist review for complex cases.
- Care coordination led by nurse case managers and including patient-specific, individualized discharge planning to reduce readmissions and improve the patient and caregiver experience.
- Transition of care (TOC) programs that combine discharge planning with in-home/ virtual/telephonic follow-up to speed recovery and lower patient risk.
- Equity-focused care, with social workers partnering directly with nurses and post-acute care facility staff to address barriers related to social determinants of health and connect patients to community resources.
Looking ahead: What’s next for post-acute care
While meaningful progress has been made on post-acute care, there’s more to do. Interdisciplinary coordination, less administrative friction and technology-based tools all have the opportunity to continue to improve care delivery.
Understanding the patient as a whole person is often the most essential first step. Risk stratification scores are used to tier patients based on their likelihood of adverse outcomes like readmission and complications. The scores range from 0–100, the higher end representing those at the highest risk. These scores are assigned after discharge from an acute setting and help improve outcomes, reduce costs and supports value-based care.
An emerging best practice is the interdisciplinary team (IDT) meeting, which brings together the patient care team and nurse case managers for regular check-ins to adjust care plans in real time. These meetings help sustain recovery momentum, ensure evidence-based care and improve long-term outcomes.
Additionally, improved electronic medical records (EMR) access across care settings enables better, faster information sharing and reduces the administrative time needed to coordinate between nurse case managers and post-acute care facility staff.
Finally, tech-enabled tools like virtual check-ins and remote monitoring can extend the reach of care teams and better engage patients and caregivers.
Finding the right post-acute care partner
Effective post-acute care requires coordination, compassion and innovation—and it demands a partner who understands both the clinical complexities and the human realities of recovery. At EviCore by Evernorth®, our model integrates all the essential elements: nurse case managers who engage early and stay connected, evidence-based clinical protocols, interdisciplinary collaboration and a focus on addressing social determinants of health that can derail even the best care plans.
The results of this comprehensive approach speak for themselves. We're able to significantly decrease long-term acute care and rehab admissions, shorten SNF stays and meaningfully reduce readmissions—all while improving the patient experience and reducing overall costs. These outcomes aren't accidental. They're the direct result of keeping patients at the center of every decision, ensuring seamless transitions between care settings and empowering providers with the support and information they need to deliver optimal care.
As the demand for post-acute services continues to grow, the need for a partner that can deliver consistent, coordinated, evidence-based care has never been greater. At EviCore, we're committed to removing friction from the care delivery process, supporting providers in their mission and ensuring that every patient receives the right care, at the right time, in the right setting. Because when post-acute care is done right, patients don't just survive their recovery—they thrive.