Becker’s Healthcare Podcast Reimagining Care Coordination Across the Continuum with Data and AI
Mar 23, 2026
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Proactive Post-Discharge Case Management
- Care coordination has shifted from reactive discharge tasks to proactive post-discharge engagement led by assigned population health case managers.
- Novella Thompson described assigning case managers at discharge who address social drivers and prevent patients from falling through an academic medical center's gaps.
Real-Time SNF Data Replaces The Black Box
- Hospital systems now use SNF EHR data and longitudinal records to follow patients in real time rather than relying on claims or repeat ED visits.
- Robin Roberts explained this visibility removes the SNF stay as a previous 'black box' for health systems.
Verify And Send Accurate Medication Lists
- Ensure accurate medication reconciliation and send the correct, current med list to post-acute partners to avoid errors at transfer.
- Novella Thompson warned that old or transposed med lists commonly arrive at SNFs and cause avoidable issues.