Overcoming Texas’ Post-Acute Care Challenges with Data

This article is sponsored by THA Partner PointClickCare. Learn more about PointClickCare here.

Texas health care providers are facing mounting pressures that threaten the quality and continuity of patient care. Staffing shortages, financial constraints, and fragmented data systems are creating gaps in care coordination—particularly during critical transitions between acute and post-acute settings. As a result, hospital readmission rates are rising, straining already limited resources. Texas’ 30-day hospital readmission rate currently stands at 15.4%, higher than the national average.

Rural hospitals are especially vulnerable, with many facing closure due to financial instability and increasing uncompensated care costs. According to the Texas Hospital Association, up to 20% of rural hospitals are at risk of closure due to ongoing financial pressures. These challenges will continue to grow unless hospitals and health care providers adopt innovative, data-driven solutions that enhance care transitions and reduce preventable readmissions.

Navigating Texas’ Fragmented Health Care System with Data
Fragmentation across care settings remains a significant challenge, particularly during post-acute transitions from hospitals to skilled nursing facilities (SNFs) or home care. When data is not shared, delayed or incomplete handoffs increase the risk of patient complications, leading to higher readmission rates. For patients, this can mean poor outcomes or prolonged recovery. For providers, avoidable readmissions are costly, as they strain resources and can result in financial penalties under value-based care models, ultimately reducing the hospital’s reimbursement and operational efficiency.

Without strong networks of care and communication, many patients may slip through the cracks during transitions, further exacerbating the problem. Health care providers are increasingly adopting data solutions to bridge these gaps. For example, TriHealth, an integrated health system, reduced inpatient readmissions by 68% using PointClickCare’s PAC Management solution. This improvement was achieved through real-time data exchange and proactive collaboration, providing care teams with timely access to patient information during transitions.

Building a Network of Care: Texas-Specific Solutions
Beyond data, Texas health care organizations are tapping into expanded collaboration networks that link acute care hospitals and post-acute providers. Recent initiatives to integrate Admission, Discharge, and Transfer (ADT) data across more than 40 hospitals have already enabled smoother transitions, with care teams receiving timely updates on patient movements and needs.

Partnerships with health information exchanges (HIEs) are further strengthening this collaboration. For example, the integration of ADT data and SNF data through the Emergency Department Encounter Notification (EDEN) network has created a more connected care experience for both providers and patients across Texas.

Addressing Social Determinants of Health
Improving care transitions also requires addressing social determinants of health (SDoH). Factors such as access to transportation, stable housing, and community support systems can significantly impact whether a patient successfully transitions from a hospital to home or a post-acute care setting. Texas has the highest uninsured rate in the nation, at 17%, meaning many patients face significant SDoH-related challenges that can interfere with their recovery.

By integrating SDoH data into care coordination efforts, providers can offer more tailored interventions that address patients’ unique needs. Incorporating these non-clinical factors helps build a clearer, more holistic picture of patient health and ultimately ensures that the interventions care teams make are both timely and appropriate. For example, arranging transportation for patients who might otherwise miss critical follow-up appointments can reduce the likelihood of readmission and improve overall outcomes.

A Proactive, Data-Informed Approach
As pressures on Texas health care providers mount, the importance of data-driven care coordination is undeniable. With data sharing, stronger collaboration networks, and a focus on addressing SDOH, providers can significantly improve patient outcomes. By proactively managing transitions between care settings, hospitals can reduce readmission rates, even in the face of increasing financial and operational headwinds.

Texas hospitals and post-acute care providers that embrace these data-informed solutions will be better positioned to deliver the high-quality care that patients need, ensuring that health care services remain robust and accessible—even in the state’s most vulnerable areas.