Staffing shortages in skilled nursing and home health, as well as lengthy insurance prior authorizations, are making it harder for hospitals to quickly discharge patients to post-acute care. Older adults with Medicare Advantage plans are waiting up to 14% longer than those with fee-for-service Medicare to transition to skilled nursing, according to the American Hospital Association.
Software company Aidin is trying to speed up the discharge process through a platform that lets hospitals find available services, including skilled nursing, home health, durable medical equipment, infusion services and transportation.
Aidin’s software tool is integrated into providers’ electronic health records system, allowing them to match patients to services that are available in real time, said Russ Graney, Aidin founder and CEO. He said the software uses AI bots to scan the services available to patients under their insurance plans and eliminates calling around to post-acute care providers about potential services.
“If the patient needs ventilator care and he’s a bariatric patient, then maybe only two of 16 nursing homes in the area might provide bariatric care and have a ventilator,” Graney said. “Being able to provide that level of information and make the shopping experience work is a big part of what we are doing with AI.”
An Aidin spokesperson said approximately 160 hospitals and 25,000 post-acute providers are using the technology. She said pricing of the software is based on the size of the organization and its needs.
St. Luke’s University Health Network in Bethlehem, Pennsylvania has been using Aidin for two years to transition patients to skilled nursing and home healthcare, said Joanna Lucas, vice president of care management. She said the software has helped reduce patient hospital stays by 0.3 days, allowing the health system to free up beds and reduce overcrowding in its emergency departments. Lucas estimated Aidin helped save St. Luke's about $7.9 million in the first year of its use.
“We have also been able to share data with our post-acute providers to help them improve their referral acceptance rate and other important quality and operational metrics,” Lucas said in an email.
Hospital readmissions are another pain point that health systems and post-acute care providers are trying to reduce. Software technology company PointClickCare’s PAC Management technology is designed to reduce that risk.
The two-year-old technology tracks patients in post-acute care and identifies problems that could lead to a hospital readmission. The AI-enhanced software connects hospitals to post-acute providers’ EHRs and alerts hospital care managers to significant changes in patients' vital signs, medication or laboratory results that could indicate they are at risk of going back to the hospital, said Brian Drozdowicz, PointClickCare’s senior vice president and general manager of acute and payer markets.
The alerts give hospital care managers an opportunity to coordinate or recommend additional care to the nursing home.
“We have had some skilled nursing facilities that have gone from 28% readmission down to 8%," he added.
Twenty-three new health systems, accountable care organizations and other organizations purchased the technology in fiscal 2024 for a total of 40 customers, said Drozdowicz.
Sentara Health, a Norfolk, Virginia-based healthcare system and ACO, is among them. It has been using PAC Management for the past year to keep an eye on patients referred to nearly 50 skilled nursing facilities in Virginia and North Carolina, according to Stephanie Hidalgo, manager of post-acute operations.
Since hospitals don’t have clinical oversight of patients once they leave the hospital, Hidalgo said PAC Management enables the health system to still support patients in nursing homes that are sometimes short-staffed.
“We can have conversations with [nursing homes] to bring [problems] to light,” Hidalgo explained. “We can say, ‘Did you see Mrs. Jones has an increased risk? Have you flagged her for the nurse practitioner to see today?’ It’s just another reminder to the skilled nursing facilities.”
Some nursing homes and hospital systems, such as Sanford Health, are evaluating PAC Management. The Sioux Falls, South Dakota-based health system already has technology to track patients discharged to its Good Samaritan Society nursing homes, but an AI tool could be more efficient, said Erica DeBoer, the health system's chief nursing officer.
She said the health system is trying to determine whether it should design its own AI tool or buy it from PointClickCare.
Belleview, Nebraska-based Hillcrest Health Services uses PointClickCare's EHR system in its six skilled nursing facilities, said Reggie Ripple, vice president of home and community services. But Ripple said the nonprofit is taking a conservative approach when it comes to the use of any AI tools.
"Our concerns are that it is advancing so fast without a lot of oversight/parameters that it seems the technology outdates itself relatively quickly," Ripple said in an email.
The market is still growing.
Software company WellSky aims to launch generative AI technology called SkySense this month that could help home healthcare companies do more with less staff. The technology will extract information from patient documents and populate it into EHRs, transcribe conversations between nurses and patients in the field and synthesize medical records for quick review, according to WellSky Chairman and CEO Bill Miller.
Miller said customers will be able to add some of Skysense's AI capabilities to their EHR systems at an affordable price and others will be integrated into the company's EHR software at no cost.
Miller expects that within 2025, there could be even more AI-based tools targeted at post-acute care.
The American Health Care Association and LeadingAge, trade groups representing post-acute care providers, said in emails that AI can help streamline processes and improve workflows. However, Scott Code, vice president of LeadingAge's Center for Aging Services Technologies, warned that AI should never be replacement for human judgment.
"AI can provide useful data insights and highlight trends, but the final determination of care needs or risk assessments must always include thoughtful human oversight," Code said in an email.
Correction: An earlier version of the story incorrectly said 23 health systems and others had purchased PointClickCare’s PAC Management technology.
