SNF Network Performance
- Utilization
- Length of stay
- Readmissions
- Transitions
- Quality
- Outcomes
- Provider variation
For Health Systems & Accountable Care Organizations
Extend Clinical Intelligence Beyond the Hospital
Maintain visibility into attributed patients across post-acute care with connected clinical data, episode intelligence, network performance insights, and transition-of-care workflows built for value-based care.
Value-Based Post-Acute Care
Your Accountability Doesn't End at Discharge. Neither Should Your Visibility.
For health systems and ACOs managing attributed populations, clinical and financial accountability often continues after the patient leaves the hospital. Yet visibility can become fragmented once care shifts into SNF, home health, and community-based settings. PAA helps connect those post-acute episodes back into the workflows of the teams responsible for quality, utilization, transitions, and total cost of care.
The Attributed Patient Journey
One Post-Acute Journey. One Clinical Intelligence Layer.
Anna® provides a common Clinical Intelligence layer across the post-acute journey, so the teams accountable for the population keep visibility at every stage.
Clinical Intelligence in the Workflow
Follow Attributed Patients Across the Post-Acute Journey
Explore each stage to see how Anna® brings the right clinical intelligence into the workflow, and the operational value it enables for attributed-population management.
Powered across the post-acute journey by Anna® Clinical Intelligence
Stage 1
Acute Discharge & Post-Acute Planning
In the patient journey
An attributed patient is approaching discharge from the acute setting and may require post-acute care.
Health system / ACO need
Identify attributed patients entering post-acute care and establish earlier visibility into the anticipated post-acute episode and transition plan.
Relevant Anna capabilities
- Attributed patient identification
- Post-acute planning
- Transition visibility
- Clinical context
- Network intelligence
- Expected post-acute needs
- Post-acute provider considerations
Associated PAA solutions
- Anna Network OptimizationSNFHome Health
- Anna Care EnablementCross-Continuum
Value Enabled
Earlier visibility. Better post-acute planning.
Identify attributed patients entering post-acute care earlier and bring clinical and network intelligence forward so teams can coordinate the episode before visibility is lost at discharge.
- Earlier Visibility
- Network Intelligence
- Transition Planning
Anna supports post-acute planning with intelligence. It does not replace hospital discharge planners.
Powered across the post-acute journey by Anna® Clinical Intelligence
Stage 1
Acute Discharge & Post-Acute Planning
In the patient journey
An attributed patient is approaching discharge from the acute setting and may require post-acute care.
Health system / ACO need
Identify attributed patients entering post-acute care and establish earlier visibility into the anticipated post-acute episode and transition plan.
Relevant Anna capabilities
- Attributed patient identification
- Post-acute planning
- Transition visibility
- Clinical context
- Network intelligence
- Expected post-acute needs
- Post-acute provider considerations
Associated PAA solutions
- Anna Network OptimizationSNFHome Health
- Anna Care EnablementCross-Continuum
Value Enabled
Earlier visibility. Better post-acute planning.
Identify attributed patients entering post-acute care earlier and bring clinical and network intelligence forward so teams can coordinate the episode before visibility is lost at discharge.
- Earlier Visibility
- Network Intelligence
- Transition Planning
Anna supports post-acute planning with intelligence. It does not replace hospital discharge planners.
Stage 2
SNF Transition & Admission
In the patient journey
The attributed patient transitions from the hospital into a skilled nursing facility.
Health system / ACO need
Know when and where the patient transitions into SNF care and begin receiving relevant post-acute clinical information without relying entirely on fragmented manual workflows.
Relevant Anna capabilities
- SNF ADT visibility
- SNF EMR integration
- Clinical document ingestion
- Clinical data ingestion
- Transition visibility
- Episode initiation
- Clinical summaries where appropriate
Associated PAA solutions
- Anna Continued StaySNF
- Anna Network OptimizationSNFHome Health
Value Enabled
Connect the SNF episode from day one.
Use ADT signals and SNF integration to know when and where attributed patients transition into post-acute care and reduce the manual effort required to gather relevant clinical information.
- ADT Visibility
- SNF EMR Integration
- Reduced Data Fragmentation
Stage 3
SNF Episode Management
In the patient journey
The attributed patient is receiving SNF care and progressing through the post-acute episode.
Health system / ACO need
Maintain visibility into the clinical episode, anticipated length of stay, clinical change, discharge readiness, and transition needs so teams can manage the episode proactively.
Relevant Anna capabilities
- Estimated length of stay
- Predicted discharge date
- SNF EMR integration
- Clinical data ingestion
- Clinical document ingestion
- Clinical Intelligence
- Clinical change identification
- Discharge readiness
- Episode planning
- Clinical summaries
- ADT visibility
- Workflow intelligence
Associated PAA solution
Value Enabled
Manage the episode proactively, not retrospectively.
Bring connected SNF clinical data, Clinical Intelligence, estimated length of stay, clinical change, and discharge readiness into the workflow so teams can recognize emerging needs and begin transition planning earlier.
- Episode Visibility
- Earlier Discharge Planning
- Proactive Management
Estimated length of stay is a guidepost that supports episode management and discharge planning, not an automated discharge decision. Anna provides Clinical Intelligence while clinical teams retain decision authority.
Stage 4
Transition Home
In the patient journey
The attributed patient approaches discharge from SNF and transitions back into the home or community.
Health system / ACO need
Identify discharge timing, transition needs, care gaps, and follow-up opportunities early enough to coordinate the next phase of care.
Relevant Anna capabilities
- Discharge readiness
- Transition planning
- ADT visibility
- Care-gap identification
- Follow-up opportunities
- Home health identification
- Care coordination intelligence
- Transition-of-care intelligence
Associated PAA solutions
- Anna Care EnablementCross-Continuum
- Anna Home HealthHome Health
Value Enabled
Coordinate the transition before the transition occurs.
Surface discharge timing, transition needs, care gaps, and follow-up opportunities earlier so care-management and population-health teams can coordinate the next phase of care.
- Transition Coordination
- Care Gap Visibility
- Follow-Up Opportunities
Stage 5
Home Health & Community
In the patient journey
The attributed patient continues recovery in home health or other community-based care.
Health system / ACO need
Maintain visibility after facility discharge and continue following clinical activity, transitions, and outcomes across home-based care.
Relevant Anna capabilities
- Home Health ADT visibility
- Home Health EMR integration
- Clinical data ingestion
- Clinical document ingestion
- Clinical summaries
- Care-gap identification
- Transition-of-care intelligence
- Follow-up opportunities
- Readmission-risk insights
- Quality and outcome visibility
Associated PAA solutions
- Anna Home HealthHome Health
- Anna Care EnablementCross-Continuum
Value Enabled
Maintain visibility beyond facility-based care.
Continue following attributed patients through home health and community-based care with connected clinical information, transition signals, and post-discharge insights that support ongoing population-health workflows.
- Home Health Visibility
- Care Continuity
- Outcomes Intelligence
Connected Post-Acute Data
Bring Post-Acute Clinical Data Back Into the Workflow
PAA connects relevant clinical information and transition signals across SNF and home health back into the workflows of the teams managing attributed populations, reducing reliance on fragmented, manual information gathering and creating more continuous visibility outside the hospital.
Connected post-acute data sources
- SNF EMRsSNF
- SNF Clinical DocumentsSNF
- ADTSNF & Home Health
- Home Health EMRsHome Health
- Home Health Clinical DataHome Health
- Home Health ADTHome Health
Anna® Clinical Intelligence Platform
Connects and organizes post-acute clinical data and transition signals into a common intelligence layer. Integrations vary by source and setting.
Health System / ACO Workflows
Clinical, Population Health, Care Management, Network, and Analytics teams.
- Reduce manual data gathering
- Improve post-acute visibility
- Support more efficient clinical workflows
- Maintain continuity across transitions
Network Performance
Turn Post-Acute Data Into Network Intelligence
Understand variation across SNF and home health providers serving the attributed population so teams can identify performance patterns, evaluate post-acute network strategy, and focus improvement efforts where they may have the greatest impact.
Home Health Network Performance
- Utilization
- Transition performance
- Quality
- Outcomes
- Readmissions
- Provider variation
Associated Solution
See where post-acute performance varies and turn that visibility into more informed network strategy.
Built for Value-Based Performance
Post-Acute Intelligence for the Outcomes That Matter
Executive-level value across the clinical, operational, and financial priorities that shape performance under accountable and value-based arrangements.
Attributed Population Visibility
Know when attributed patients enter, move through, and exit post-acute care so teams can maintain visibility beyond the hospital.
Post-Acute Episode Management
Use Clinical Intelligence, connected clinical data, and episode guideposts to support more proactive management across SNF and home-based care.
Connected Post-Acute Data
Reduce fragmentation by bringing relevant SNF, home health, clinical-document, and transition data into health-system workflows.
Network Performance Intelligence
Understand variation across SNF and home health providers to support more informed network and care-transition strategies.
Total Cost & Quality Performance
Create visibility into the post-acute factors influencing utilization, length of stay, readmissions, transitions, quality, and total cost of care.
Powered by Anna®
One Clinical Intelligence Platform for Value-Based Post-Acute Care
Anna® brings clinical context, connected post-acute data, and network intelligence together so health systems and ACOs can manage attributed patients more consistently across settings, teams, and episodes of care.
Anna® Clinical Intelligence Platform
Relevant solutions for health systems & ACOs
- Anna Continued Stay
- Anna Home Health
- Anna Care Enablement
- Anna Network Optimization
These are applications of one Clinical Intelligence Platform, not separate systems.
Trusted at Scale
Trusted by the Nation's Leading Health Plans, Health Systems, and Post-Acute Providers
- Patients supported
- 11M+Patients supported
- Largest Medicare Advantage plans
- 4 of 5Largest Medicare Advantage plans
- Leading U.S. health systems
- 7 of 10Leading U.S. health systems
- Post-acute providers connected
- 7,000+Post-acute providers connected
Outcomes That Matter
Where Post-Acute Intelligence Shows Up in Value-Based Performance
The areas below represent where Anna® is designed to support measurable improvement for organizations accountable for attributed populations.
- Post-acute utilization
- Length of stay
- Readmissions
- Care transitions
- Network performance
- Quality outcomes
- Total cost of care
Extend Your Value-Based Care Strategy Into Post-Acute Care
See how Anna® can help your teams maintain visibility, connect post-acute data, and manage attributed patients across SNF, home health, and the transition home.