The Post-Acute Care Plan (PACP): A Concept Paper
A proactive approach to discharge readiness and system-level flow improvement.
Abstract
Complex discharges are delayed because discharge-critical inputs are collected during crisis rather than before admission. The Post-Acute Care Plan proposes capturing these inputs proactively in routine care so hospitals, patients, and downstream providers can execute with fewer avoidable inpatient days.
What This Paper Contributes
- Frames complex discharge as an upstream input-quality problem, not a downstream heroics problem.
- Defines a PACP data model for legal authority, financial coverage, placement preferences, and social support.
- Shows how pre-admission capture converts discharge from crisis improvisation into coordinated execution.
- Connects discharge friction to broader district-level boundary constraints and community infrastructure choices.
Key Numbers Highlighted in the Paper
25%
Estimated avoidable hospital days in analyzed fee-for-service claims datasets.
10.8M
Approximate annual avoidable inpatient days extrapolated in the concept argument.
29,590
Equivalent beds occupied year-round by patients who no longer require acute-level care.
PACP Data Domains
- Legal and decision-making: POA status, agent availability, guardianship risks.
- Insurance and financial: payer constraints, authorization likelihood, known coverage gaps.
- Placement preferences: preferred facilities, geographic limits, explicit exclusions.
- Home environment and support: caregiver reality, safety constraints, practical barriers.
- Preferences and values: patient priorities for post-acute setting and tradeoffs.
- Risk flags: constraints likely to trigger delay if discovered late.
Implementation Position
The paper argues for phased implementation through primary care touchpoints, targeted prioritization, and maintenance logic that updates plans as conditions change. It also addresses interoperability and public-district implications where discharge performance depends on community resources outside hospital control.
Publication Metadata
- Author: John Sambrook
- Document type: Concept paper
- Version: 1.4
- Initial release: November 2025
- Current revision: December 2025
References and Sources
The paper includes a full references section. Key external sources used in the current revision are listed below.
- American Hospital Association: Delays in discharge increase strain on patients and hospitals
- AHA: The Cost of Caring (2025)
- Advisory Board: Identify and Address Avoidable Hospital Days
- Minnesota Hospital Association: 2023 discharge delays cost analysis
- Dr. Robert Bree Collaborative: Complex Patient Discharge Recommendations
- Washington State Reports to the Legislature
- National Institute on Aging: Advance care planning
Request for Feedback
This paper is published as working intellectual output. Critical review is welcome, especially on assumptions, implementation barriers, and falsification cases. If you have field experience that challenges the model, I would value that input.