Reducing Readmissions Starts With a More Connected Post-Acute Journey

Reducing Readmissions Starts With a More Connected Post-Acute Journey

Hospital readmissions are often discussed as an outcome. But many of the opportunities to prevent them occur much earlier, particularly as patients move between care settings and critical information needs to move with them.

That challenge is especially visible in post-acute care.

A patient may transition from the hospital to a skilled nursing facility, then return home with home health services. Along the way, different organizations, care teams, and technology systems may be involved. Each transition creates another opportunity for clinical information to become fragmented or delayed.

A recent Modern Healthcare feature explored how healthcare organizations are working to close these gaps, including the work underway at OneHome, part of CenterWell, using Anna®, Post Acute Analytics' Clinical Intelligence Engine.

Care Transitions Are Clinical Moments

Moving a patient from one setting to another is more than an administrative handoff.

The information available before and immediately after that transition can influence whether the next care team understands the patient's current condition, whether needed services begin when expected, and whether emerging risks are identified early enough to act.

Modern Healthcare highlighted the challenges created when post-acute providers operate across different electronic health record systems. When information does not move seamlessly between skilled nursing and home health, important context can be difficult to carry forward with the patient.

The opportunity isn't simply to create more data. It's to connect the information that already exists and make what matters available to care teams when they need it.

Connecting the Post-Acute Journey

OneHome is putting that approach into practice with Anna®.

Modern Healthcare reported that approximately 2,500 skilled nursing facilities across 21 states had integrated Anna® into their workflows. The publication also reported an approximately 3% decrease in readmission rates in the first quarter of 2026 compared with the same period the previous year among facilities using the platform. Anna® is also expanding across more than 300 CenterWell Home Health locations and other referral partners.

Those results are meaningful, but the larger opportunity is the ability to understand the patient's journey across settings rather than viewing each care setting in isolation.

From Managing Settings to Understanding the Episode

Patients don't experience skilled nursing, home health, care transitions, and readmissions as separate workflows. They experience one recovery journey.

For health plans and health systems, that creates an opportunity to think differently about post-acute care.

What happened during the skilled nursing stay? Is the patient ready to transition? What support will be needed at home? Did that care begin as expected? Is something changing that could indicate increased risk?

Clinical Intelligence can help connect those moments by bringing relevant information into the workflows where clinical decisions are already being made.

At Post Acute Analytics, that's the future we're continuing to build with Anna®: giving care teams the right information, in the right context, at the right moment to support more informed decisions across the post-acute journey.

See the results in practice: Explore our case study on how OneHome is using Anna® Clinical Intelligence to connect skilled nursing and home health workflows and help reduce hospital readmissions.