Creating a Seamless Transition from Acute to Post-Acute Care

On June 6, 2023, CMS issued QSO-23-16-Hospitals summarizing their commitment to ensuring the health and safety of patients when discharges from hospitals and transfers to post-acute occur. The memorandum outlines recommendations hospitals can utilize to improve their discharge policies and procedures and protect patients’ health and safety. Failure to provide complete and accurate information to the receiving provider can place the patient’s health at risk and may also put the health and safety of other residents in the facility at risk, creating avoidable readmissions, complications, and other adverse events. When end-of-life preferences are not clearly communicated and documented, patients may receive treatments that are unnecessary and inconsistent with their wishes.

This increased focus on ensuring a smooth discharge transition for patients and providers encourages post-acute providers to implement best practices that address the following:

  • How can post-acute providers implement best practices and collaborate effectively with their referring hospitals?
  • What are the most common areas of concern during the transition from acute to post-acute care?
  • What practices can post-acute (PAC) providers adopt to ensure an effective admission and discharge process as their patients move through the continuum of care?
  • What resources are available to assist with the transition of care? 


  • Start the discharge planning process at the time of admission and engage the patient and family early
  • Ensure the patient and/or their representative understand discharge instructions
  • Match patients’ needs with PAC providers’ services – hospital case managers and social workers should know the strengths of the providers in their communities. Communicate clearly with the PAC to ensure they are equipped and trained to care for any special needs the patient may have
  • Make sure comprehensive information flows from the hospital to the post-acute setting by extracting the most important information. It can be tempting to send the entire chart, but sorting through voluminous amounts of documents becomes overwhelming and much of it is not meaningful to the receiving facility
  • Encourage the utilization of standardized processes and forms such as
  • Review and consider recommendations in AHRQ Re-Engineered Discharge (RED) Toolkit:


  • Patients with serious mental illness and complex behavioral needs and/or substance abuse disorder. While information about the acute condition may be included, there is often little history provided to the receiving facility about underlying diagnoses and prior treatments
  • Information on whether the patient had additional supervision in the acute care setting that were recently discontinued – i.e., sitters, 1:1 care
  • Comprehensive medication list including diagnoses/clinical indications and clear post-discharge orders including time of last dose and time next dose is due. For medications requiring a therapeutic range, include most recent lab work
  • Skin conditions including orders and instructions for treatments/dressings
  • Durable medical equipment such as Trilogy, CPAP/BiPap or high-flow oxygen as well as specialty mattresses, wound vacs, and any other specialty equipment
  • Communicate any special medication needs to PAC
  • Patient’s preferences and goals for care including advance directives


  • Get to know your referring providers and collaborate on a clear and concise process for ensuring an appropriate flow of information and ensure acute care providers are aware of the facility’s strengths and the types of conditions the facility is trained to care for
  • Work with the hospital’s discharge planners to establish a “point person” for questions/follow-up needs
  • Work with hospitals to enable access to patient information in their electronic health records (EHRs)
  • Inquire as to any types of patients the hospital is treating and discharging to PACs and arrange for training and develop competencies for those conditions to prepare for more acutely ill and special needs patients
  • Inquire about special treatments, procedures, and specialty medications prior to accepting the referral and admission to arrange for timely delivery
  • Ensure the facility has a welcome process for new admissions to greet patients and ensure their comfort promptly upon arrival. Review discharge paperwork timely and order medications promptly
  • Communicate with the pharmacy to develop policies and procedures to provide timely medication delivery and an adequate emergency supply of medications
  • Meet with designated hospital staff and agree on performance commitments and on a performance measurement process that enables all parties to monitor what is working and what is not, quickly identify issues, and establish ongoing improvement priorities

    Consulting Services
Contact Us

LeaderStat specializes in direct care staff, interim leadership, executive recruitment, travel nursing and consulting for healthcare organizations nationwide.