The Post-Acute Care Plan (PACP)
A Proactive Approach to Discharge Readiness
"Treating discharge delays as an input quality problem, not a process problem."
Executive Summary
According to Advisory Board data, 25% of hospital days are avoidable. These aren't days consumed by clinical care—they're days lost to waiting: waiting for paperwork, waiting for insurance verification, waiting for family decisions that should have been made long ago.
The core problem isn't that hospitals discharge poorly. It's that the information required for a smooth discharge—legal authority, financial eligibility, placement preferences, social support—is treated as something to be discovered during a crisis rather than captured in advance.
The Structural Barrier
Hospitals have spent decades trying to optimize their internal discharge processes. They've added case managers, created discharge checklists, implemented daily huddles, and invested in care coordination platforms. Yet discharge delays persist.
The reason is structural: discharge depends on external constraints that hospitals cannot control operationally. Power of Attorney status isn't a hospital process. Medicaid eligibility isn't determined by the care team. Family dynamics and SNF preferences don't originate within hospital walls.
This creates what clinicians experience as moral distress. Case managers are tasked with resolving problems that are, by design, structurally unsolvable within the hospital context. They burn out not from laziness or incompetence, but because the system asks them to produce outputs from inputs they don't have and cannot create.
The Input Analogy
Manufacturing understood this decades ago: if a factory wants to improve output quality, it improves input quality. You don't fix defects at the end of the line—you prevent them at the beginning.
The Post-Acute Care Plan applies this principle to hospital discharge. Rather than asking case managers to assemble critical information under time pressure during an acute stay, the PACP captures this data before admission—during routine primary care encounters when patients and families can make considered decisions without the stress of a health crisis.
The result: discharge transforms from "crisis management" into "coordinated execution." When a patient is admitted, the discharge plan is already substantially complete.
The PACP Data Model
The PACP organizes discharge-critical information into four domains, each capturing data that is routinely unavailable at the point of need:
Legal & Decision Making
- Target Data Points
- Healthcare POA status, Agent contact info, Backup agent, Guardianship status, POLST
Why: To resolve authority constraints before they become legal delays.
Insurance & Financial
- Target Data Points
- Current verification, MA plan specific coverage, Medicaid eligibility likelihood, Long-term care insurance
Why: To prevent "retroactive denial" surprises.
Placement Preferences
- Target Data Points
- Ranked preferred SNFs (3–5), Geographic constraints (“within 30 mins of daughter”), Explicit exclusions (“Not Facility X”)
Why: To convert crisis decision-making into informed execution.
Social & Practical
- Target Data Points
- Physical environment (stairs/ramps), Primary caregiver availability (24/7 vs. evenings), Pet care arrangements
Why: Practical barriers (like pets) delay discharge as often as medical ones.
When these four domains are populated before an acute event, the hospital's role shifts from information gathering to plan activation—a fundamentally different and far more efficient operation.
Ready to Explore the PACP?
Learn how pre-admission data capture can transform your discharge outcomes.