Post-Acute Placement Navigator

The Post-Acute Placement Navigator simplifies one of the most complex steps in the discharge process, matching patients to the right post-acute facility at the right time. It centralizes outreach, status tracking, and transportation coordination across skilled nursing facilities (SNF), home health agencies (HHA), inpatient rehab (IRF), LTAC, and hospice partners.

Rather than juggling spreadsheets, faxes, and phone calls, discharge planners and social workers use a unified console to send referrals, monitor acceptance responses, and confirm transportation logistics. Capacity indicators and acceptance status updates appear in real time, enabling faster placement decisions and more predictable bed turnover.

Benefits

• Faster placements: Reduce delay between discharge readiness and confirmed post-acute acceptance through live capacity feeds and automated notifications.
• Reduced length of stay: Minimize inpatient bottlenecks by synchronizing partner outreach, approvals, and transport arrangements in one place.
• Better partner visibility: Build transparent, data-driven relationships with SNF and HHA networks through shared dashboards and standardized communication workflows.
• Audit-ready documentation: Record every referral, response, and acceptance timestamp for compliance and throughput reporting.

Key Capabilities

• Partner directory & capacity signals: Maintain an up-to-date directory of post-acute providers with bed counts, service specialties, and coverage areas.
• Referral & status tracking: Send structured referrals with FHIR Task or 360X transactions, and receive real-time ACK, HOLD, or ACCEPT status updates.
• Smart matching logic: Filter partner options by location, payer, language, or specialty service to streamline referrals and reduce rework.
• Transportation scheduling integration: Coordinate pick-up times and transport vendor assignments directly from within the discharge workflow.
• Escalation & follow-up timers: Auto-generate follow-up tasks when placement or transport confirmations exceed SLA thresholds.
• Throughput dashboard: Display unit-level metrics on open referrals, acceptance lag time, and partner response performance.

Great for

• Discharge Planners and Social Workers: Coordinate SNF, HHA, IRF, LTAC, and hospice placements through structured outreach, capacity tracking, and transport scheduling workflows.
• Health Information Management (HIM) and Throughput Teams: Reduce inpatient LOS and improve discharge readiness documentation using real-time acceptance updates and placement performance dashboards.
• Clinical Informatics and EMR Analysts: Govern referral routing and status logic, monitor partner response metrics, and surface discharge bottlenecks using dashboard overlays and HL7/FHIR integration signals.
• Post-Acute Network & Partnership Leaders: Analyze partner response patterns, identify capacity gaps, and guide network optimization using response-time analytics and acceptance trend views.