Health systems are under growing pressure to move care out of acute settings driven by capacity constraints, workforce shortages and payer restrictions. Advances in artificial intelligence and remote patient monitoring help facilitate that move — often closer to or into patients’ homes.
Becker’s asked 25 post-acute care leaders from health systems across the country: What are you most excited about in post-acute care as we head into the end of the year?
Some common threads appeared among the answers:
- Home is becoming the new destination of care through hospital-at-home, SNF-at-home or expanded home health.
- Post-acute is being repositioned as a strategic driver, rather than an afterthought.
- Stronger connectivity is being built between acute and post-acute partners
- AI and remote patient monitoring are powerful tools for reducing readmission, proactive outreach and extending clinical reach without adding work.
Editor’s note: Responses have been lightly edited for clarity and length.
Matthew Bartels, MD. Professor and Chairman of the Department of Rehabilitation Medicine at Montefiore Einstein (New York City): Post-acute care is an ever-changing and evolving part of healthcare. The greatest opportunities that are now being realized include the ability for family members to have payment for providing home services for their loved ones, as this markedly increases the number of health aides available and also allows family members to be able to provide care for their loved ones while still maintaining income. Another area of great potential for post-acute care may come in the form of automation and robotics. In Japan, for example, robotic devices and companions are helping people in post-acute care settings. Some of the robotic devices can help with heavy lifting or provide therapy in a home or post-acute care setting.
Additionally, with AI incorporation, some of the devices can become companions who can maintain socialization and also provide assistance to people who need supervision in a post-acute care setting. These companions come in the form of humanoid devices, but also animals, and can be reassuring company for people who live alone or are not able to socialize in usual settings. And finally, the potential to create pathways of care using unified health records may allow for a smoother and more efficient transition of patients from acute hospitalization into a rehabilitation setting — whether acute rehabilitation or nursing home-level care — and then assure transition to home therapy and outpatient services.
The use of unified records will help identify challenges for patients and allow for the appropriate application of services to the patient who requires it while avoiding the use of services that are not needed in situations where patients require a lower level of care. Leveraging big data and the assistance of AI may help create and recognize these more efficient pathways, limiting time in the acute care hospital and other institutional settings while also maximizing benefits for patients.
Patricia Buiocchi, BSN. Chief Operating Officer of Post-Acute Care at MaineHealth (Portland, Maine): What excites me most about post-acute care is that we’re finally moving from a reactive model to a predictive model of care. As hospitals care for increasingly complex patients and focus on reducing length of stay, post-acute providers are becoming the connective tissue across the healthcare continuum.
Technologies such as remote patient monitoring, predictive analytics and virtual care are giving clinicians real-time visibility into patient status, allowing us to identify concerns earlier, prevent avoidable hospitalizations and deliver high-quality care where patients overwhelmingly want to be: at home. Combined with stronger value-based partnerships, we’re seeing post-acute care evolve from a downstream service into a strategic driver of outcomes, patient experience and total cost of care.
Peter Chang, MD. Senior Vice President, Chief Transformation Officer at Tampa (Fla.) General Hospital: TGH has a very robust hospital-at-home program, and to me, the exciting part is the blurring of the transition points — taking that acute inpatient care into the home. I think that’s vital for us to look at, both for decreasing the cost of care across the entire care continuum and for increasing the quality of care we deliver.
With that care transitioning to the home, it actually supersedes placement into some traditional post-acute settings. Often, families are concerned — they don’t want their loved one to go to a facility like a skilled nursing facility or even inpatient rehab. If we can figure out ways to transition that care to the home, hospital-at-home is one avenue. But of course, that’s going to run its course, and the patient will become eligible for discharge. Figuring out the support services the patient would be eligible for after discharge is the next step in our process.This idea of transitioning higher-acuity care to the home is, in a sense, “post-acute” because it’s still inpatient care that we’re delivering at home.
Jane Cipriano. Director of Post-Acute Service Line of Concord (N.H.) Hospital: Since launching the Skilled and Restorative Care program at Concord Hospital-Franklin in FY24, we have seen a steady increase in admissions from 34 in FY21 to 319 so far in fiscal year 2026. We are excited about the growth of the program and being able to provide a subacute level of care to patients within the health system who require short-term nursing and rehabilitation prior to returning home. We have not only seen orthopedic patients in the program, but also patients needing complex medical management, wound care and frequent IV antibiotic therapy.
We are also excited to begin the phased renovation project at CH-Franklin. We will start with relocating the rehab space to the first floor, which will provide a larger space for rehabilitation therapy – physical, occupational and speech. There will be a cognitive testing room as well as a mock apartment, which will allow patients to simulate their return home. After the rehab move, we will begin renovating the 2South unit, including all patient rooms and common spaces.
Diane Ehn. Vice President of Post-Acute Care for the Froedtert & the Medical College of Wisconsin Health Network (Milwaukee): I’m most excited about how rapidly technology is advancing to strengthen coordination across the care continuum. Better integration between health systems and post-acute care providers is improving real-time information sharing, data analytics, and communication during care transitions. These tools help identify patient safety concerns, match patients to the most appropriate level of care, and support seamless care coordination across settings. The ability to access and share information in real time creates greater awareness of patients’ needs and allows health systems and post-acute partners to address challenges more quickly and collaboratively. Together, we can identify solutions that improve both patient outcomes and the care experience.
I’m also encouraged by the continued growth of population health and community-based services that help patients receive care in their homes and avoid unnecessary hospitalizations. Innovations such as telehealth, home-based care, remote monitoring, self-scheduling tools and stronger connections to community resources are making care more accessible and personalized.
Melissa Frias. Interim President and COO, CNE VNA of Care New England, and Executive Director of Kent Hospital at Home, Geriatrics and Palliative Care (Providence, R.I.): I am very excited about the continued maturation and scaling of “hospital at home” and higher-acuity VNA models. We are moving past the early adoption phase into a period where data proves these programs work. The historical boundaries between traditional home health and acute hospital medicine are blurring in a way that allows us to treat complex patients where they are most comfortable and thrive best — in their own homes. This shift is being fueled by remarkable advancements in technology.
By leveraging passive, continuous remote patient monitoring and real-time biometric tracking, our clinical teams can proactively detect physiological anomalies and intervene before they escalate into emergencies. Seeing the definitive data on reduced hospital-acquired infections, lower delirium rates and higher patient satisfaction scores in the home environment is incredibly validating.
Danna Lamont, DNP. Nurse Practitioner Lead for Post-Acute Care Services; Thuan Ong, MD. Medical Director for UW Post-Acute Care Services at Harborview Medical Center; Mengru Wang, MD. Assistant Professor of Division of Gerontology and Geriatric Medicine at UW Medicine (Seattle): We are both excited and cautiously optimistic about the growing role of artificial intelligence and predictive analytics in post-acute care. These technologies have the potential to anticipate health outcomes and complications, identify which patients may benefit most from post-acute services guide care that is tailored to an individual’s needs. By more accurately aligning patient demand with available staffing, these innovations can enhance operational efficiency while improving patient outcomes. It is also encouraging to see increased attention being given to post-acute care, a sector of healthcare that many stakeholders do not fully understand despite frequent interfacing with hospital discharge planning, potential to prevent avoidable hospital discharges, and critical role in patient recovery. As predictive tools become more integrated into care planning and resource allocation, they create an opportunity to better demonstrate the value and impact of post-acute services across the continuum of care.
Mary Mathieu, DNP, MSN, RN. Director of Continuity Care at Lowell (Mass.) General Hospital: On April 29, the Massachusetts Health Policy Commission, announced it would be awarding $1.38 million in total funding to seven acute care hospitals in the State of Massachusetts. This funding is part of a new Promoting Appropriate Transitions to Home (PATHways) investment program and aims to streamline a process by which older patients discharge to their home setting with community-based services versus discharge to an institutional setting.
I am delighted to report Lowell General Hospital is one of the recipients of this program. This is an exciting opportunity for us to further strengthen our existing relationship with our local Aging Service Access Point (ASAP), AgeSpan. Together, we more effectively and efficiently coordinate transition efforts for our patient’s post-acute care needs, advocate for skilled nursing facility diversions and well-coordinated transitions to home and community-based settings with home and community-based services. We expect patients that participate in this program will spend less time in the hospital, have a greater opportunity to discharge to the least restrictive setting, that is to discharge home with services instead of discharging to higher levels of care, and will likely have less unnecessary readmissions to the hospital setting.
Aashka Mehta. Vice President of Post-Acute Care at Cone Health (Greensboro, N.C.): I think post-acute care is no longer being viewed as a downstream service. Organizations are recognizing it as a truly strategic component of the health system — it’s not an afterthought like it used to be. I’m really excited about the connectedness we have here in the Triad with our post-acute partners, whether that’s a skilled nursing facility, home health, hospice or long-term care — I’m not bucketing it to only the nonprofit organizations we work with. I bring nursing homes quarterly to our education building here in Union Square and host a town hall meeting where we go over scorecards. We used to do that before COVID-19, and I’m restarting it. I do that with home health agency partners too, so each partner gets their scorecard. What does a good partnership look like? More and more, it’s fascinating.
Last week I was at a SNF conference, and this is what excites me: Someone said, “Hey Aashka, you said this patient would get here timely — let me tell you what happened,” and they’re calling me out, and I love that relationship. They’re also coming to me saying, “Can we do a transportation pilot?” That’s what excites me. At the end of the day, we’re making a genuine difference in aging and elderly care, because this could be someone’s last stop — a veteran, somebody’s mother, it doesn’t matter. That’s what Cone Health does: build really good relationships and make sure aging and elderly patients are taken care of. That’s what floats my boat.
Katrina Melton. Vice President of Post-Acute and Palliative Care at Sentara Health (Norfolk, Va.): What excites me most about post-acute care is our ability to truly meet patients where they are and help them achieve their personal goals in the place they most want to be — their home and community. The beauty of post-acute care is that we have the privilege of impacting not only a patient’s recovery, but often their quality of life, independence and well-being for years to come. Every year, I am inspired by the opportunity to see patients and families thrive in their own environment, surrounded by loved ones. We are invited into some of life’s most vulnerable moments, and it is an honor to help individuals navigate complex healthcare needs while preserving their dignity, independence and connection to the people and places they love.
I am also encouraged by the growing recognition that aging in place can lead to better outcomes, improved function and a higher quality of life. Patients and families increasingly want care that supports them where they are rather than requiring them to leave their homes and communities. Post-acute care is uniquely positioned to make that possible. What makes the future especially exciting is the opportunity to combine compassionate, relationship-based care with innovation. I often describe the future of post-acute care as the intersection of high-tech and high-touch. Advances in artificial intelligence and other technologies are helping us identify patient needs earlier, improve care coordination and reduce administrative burden. The greatest value, however, is that these tools will allow our clinicians to spend more time focused on what matters most: the patient and family in front of them.
Shawn Parekh, PharmD. CEO of Roxborough Memorial Hospital (Philadelphia): At Roxborough Memorial Hospital, located in Northwest Philadelphia, we are deeply committed to collaborating with our post-acute care partners to ensure patients receive the appropriate level of care following hospitalization. Strong partnerships between acute care hospitals and post-acute providers are essential to determining the right discharge destination, supporting continuity of care and helping patients maintain their health and independence after leaving the hospital. Many patients require skilled services beyond discharge, making access to high-quality post-acute care an important part of the overall patient care journey.
Roxborough Memorial Hospital further supports access to these services by expanding inpatient rehabilitation facility resources in the community, providing an additional service for patients who require continued rehabilitation and recovery following hospitalization. Access to appropriate post-acute care remains an important part of supporting patients throughout their recovery. We remain committed to working with our community partners and utilizing all resources available to help ensure patients have access to the care and services they need at the appropriate time and in the appropriate setting.
William Pesce, DO, Chief Medical Officer at Hospital for Special Care (New Britain, Conn.): I am proud of what we have been able to accomplish through partnership to help medically complex patients access the long-term rehabilitation care they need. By building strong relationships with the acute care hospitals in our area, we have been able to improve the transition of patients to post-acute care and ensure patients receive the right level of care. Improved collaboration and resource sharing with the National Association of Long Term Hospitals also helps us navigate insurance barriers that often arise when evaluating post-acute care for patients who need the highest level of medical and rehabilitative services. While we will continue to face challenges with insurance authorization, our collaboration with NALTH enables us to be stronger advocates for patients, particularly those who may require longer periods of care following a severe brain or spinal cord injury.
What is most exciting are improvements coming to our rehabilitation services to provide a more personalized approach for patients. Thanks to the vision and commitment of our Board of Directors and Corporators, we are renovating an existing inpatient unit to expand our rehabilitation capacity with 10 private patient rooms, as well as add state-of-the-art nursing, clinical, and support spaces to deliver specialized care. These enhancements will provide greater flexibility to meet the needs of patients with a broad range of medical complexities, and will help us better serve our local acute care partners.
Troy Powell. COO of Ambulatory and Post-Acute Operations at Roper St. Francis Health (Charleston, S.C.): Post-acute care continues to shift similarly to acute care in that where and how patients receive care is evolving. Advances in technology, remote monitoring, payer pressures and patient preference are driving more patients to home-based care, and how quickly this space is growing is exciting. We feel there is an opportunity to further leverage our home-based care platform to not only meet patients where they desire to have care but also support our acute care channel, improving throughput and patient transitions. These same forces are also challenging our inpatient post-acute services, as lengthy and stringent prior authorization processes make it more challenging for patients to utilize services such as inpatient rehabilitation. Collectively, this shift is accelerating growth in home-based and ambulatory post-acute care and constraining growth in inpatient post-acute settings.
In light of these shifts, I feel we have to rethink how we provide post-acute care. Instead of a fragmented continuum, we need to leverage technology and develop the full range of services that support the patient journey and care outside of the acute care hospital. What we call post-acute care should be viewed as supporting the patient just as much on the front end as the back end of an acute episode.
Ultimately, I believe the organizations that will be most successful are those that stop viewing these services as what happens “after” acute care and instead manage the entire patient journey as one connected continuum. That shift — from individual sites of care to a system of care — is another exciting aspect of where our industry is headed.
Mara Prandi-Abrams. Patient Flow Administrator at Denver Health (Denver): Post-acute partnerships and the levels of care that are missing. We’re in a lot of discussions right now about policy change. For example, we’ve got many patients with behavioral health diagnoses and also 1 in 5 of our adult patients is experiencing homelessness. So when we think about our post-acute strategy, it’s really about how we meet all of those patients’ needs at the most appropriate level of care based on their unique set of circumstances.
Susan Sales. CEO of NYC Health + Hospitals/Gouverneur (New York City): We’re always looking to diversify and enhance our services. In the next month or so, we’ll be opening an on-site dialysis center — something we’ve identified as a need for our residents, especially highlighted during COVID-19, when getting to off-site dialysis meant going out in the winter months by ambulette, missing meals and coming back through snow, rain and ice. So the opening of our on-site dialysis center is exciting. Our main focus in rehabilitation is subacute rehab, but we also continue working with our long-term residents to help them live at the highest practical level. Over time, we’ve seen success in placing people back in the community through rehabilitation, and — though it’s not always available — into assisted living or independent living with services. I think it’s really exciting that we can return people to the community after they’ve lived with us for a period of time.
As a skilled nursing facility administrator who also worked on the hospital side earlier in my career, the difference is there’s much more connection with the person receiving services and their family. I’m not just pushing papers — I see the fruits of my labor in happy families and residents who enjoy living in our environment. We’re also very lucky to have a beautiful building with all private sleeping quarters facing the East River on the Lower East Side of Manhattan. Those are some of the exciting things for me.
Melissa Seccareccio, MSN, RN. Executive Director of Care Coordination at Southern New Hampshire Health (Nashua, N.H.): What I’m most excited about in post-acute care right now is the increasing focus on helping our aging patients recover and stay healthy in the community, rather than relying solely on traditional healthcare settings. We’re seeing stronger collaboration between hospitals, primary care providers, skilled nursing facilities, home health agencies and community organizations. There are more tools and resources available to support patients after discharge, and that’s creating opportunities to improve outcomes while helping people remain independent and engaged in their own care.
What gives me optimism is that healthcare organizations are working together more closely than ever before. We know it takes a village to care for our community. As we continue to strengthen partnerships across the continuum of care, we also aim to expand innovative approaches, such as applying the fundamentals of an age-friendly health system and strengthening cross-continuum care coordination. We have a real opportunity to improve the patient experience, reduce avoidable hospitalizations and better support individuals where they want to be, which is often in their own homes.
Mona Siddiqui, MD. Senior Vice President of Home and Community Care at Highmark Health (Pittsburgh): This is such a broad topic. I’d say we’re seeing a lot more care shift into the home. We’re also seeing that as patients experience different types of care in the home that they used to get in the hospital, there’s increasing demand for more of that. In some of our programs, like hospital at home and skilled nursing facility (SNF) at home, once folks have experienced it the first time, we have people asking for it over and over again, and our satisfaction and safety scores are really high. So the demand is growing organically, which is exciting — that’s the way we want to grow. That’s on the newer models like hospital at home and SNF at home. In some of the more traditional models — home health, hospice and those areas — I think there are so many ways of connecting the different things happening in the home. We have businesses providing home infusion services, home medical equipment, home health and hospice, which all function well independently.
But one of the things we’re really working on is creating a connected patient experience across all of these businesses. If someone is using home infusion, they’re probably going to use home health at some point too, if they’re not using it at the same time. So how do we connect the dots so it doesn’t feel to patients like there are multiple people showing up at the home with different services who don’t know what the other service is providing? We think there’s a lot of value in having a connected health platform for the home across these different verticals, and Highmark is in a unique position because we have all of these businesses — I don’t think many plans or health systems have that — so we can create this connected home care ecosystem.
The other thing I’d say is that people often underestimate the ecosystem of care happening in the home. There’s obviously the brick-and-mortar system of a hospital, and then there’s this entire ecosystem of care happening in the home. One of the connectivity points we need to do better on is between the brick-and-mortar setting and the home. The home ends up being a black box for a lot of providers as they send patients out of the acute facility, and we think there’s an opportunity for greater connectivity and information-sharing there as well. That might not seem like amazing innovation, but I think it improves the patient experience — connectivity provides confidence for the provider sending the patient home, and for the patient, knowing that information is flowing back in a way that things are connected, so they don’t have to be the glue between the two systems.
Cathy Smith. Executive Director of Rehab Services at WakeMed Health & Hospitals (Raleigh, N.C.): The most exciting developments for me are all the things happening around us, particularly in the form of artificial intelligence and remote therapeutic monitoring, which allow us in the therapy world to monitor patients beyond in-person visits. There’s also been an advancement in what we call “prehab,” or prehabilitation. A lot of the programs we’re developing now have patients doing work prior to surgeries or cancer treatment, and these services offer such a step forward in the rehab process — post-acute-wise, patients are farther along than they would be without them. It’s been incredible to do the education pieces so patients coming out of cancer treatment or advanced surgeries are more knowledgeable about what’s needed and able to do the work.
At WakeMed, we also have advanced recovery programs that look at the whole comprehensive piece of a patient’s recovery — hydration, nutrition, combating nausea and other issues. So the post-acute environment looks a lot different now, and we’re evaluating the right level of care needed for the patient, with a huge focus on return to home. That piece — the advancement and development, helping patients be more knowledgeable, and making better progress and outcomes — combined with all of these new ways of providing post-acute services and reaching patients virtually and through other channels, is really exciting.
Tim Switaj, MD. Vice President and Chief Population Health Officer at WellSpan Health (York, Pa.): What I’m excited about is how technology, such as artificial intelligence (AI) and remote patient monitoring (RPM), is advancing to meet more of our post-acute needs. The ability of AI to proactively reach out to patients during the post-acute period to ask how they are doing and allow for escalation to a clinical team member in real time can markedly improve our ability to manage these high-risk patients with our limited human resources. RPM is rapidly expanding the disease states that can be monitored remotely, allowing more patients to go home in lieu of needing placement in a post-acute facility. RPM can also aid in shortening inpatient and post-acute lengths of stay and contribute to reducing readmissions through the high-risk post-acute period.
Regina Tarkovsky, MD. Post-Discharge Acute and Transitional Care Physician Leader at Maimonides Medical Center (New York City): What excites me about post-acute care is the opportunity to create a new moment in the patient journey, one that historically has not really existed. Instead of treating discharge as the end of an episode, we can make it the beginning of a more deliberate phase of recovery. It gives us the opportunity to stay close to the patient long enough for their real needs to emerge. Some are obvious immediately, but others only become visible once the patient is back in their own environment — trying to walk to the bathroom, manage multiple medications, eat differently, sleep, regain strength or make sense of what a new diagnosis now means in everyday life. That is where post-acute care can become deeply meaningful. We are not simply extending care — we are creating the time and space for recovery to unfold with clinical support around it.
Jennifer Vennare, DNP, RN. President of UPMC at Home and Vice President of Population Health at UPMC (Pittsburgh): What excites me most is how we’re making it easier for people to recover and manage their health at home. When care is connected across hospitals, outpatient settings and the home, people spend less time navigating and more time focusing on recovery. We’re supporting this through stronger care coordination, virtual health visits, real-time remote monitoring at home and specialized home-based programs for people with complex health needs. When people can safely recover at home with the right support, they often experience shorter hospital stays, fewer complications and a lower likelihood of returning to the hospital unexpectedly. It also helps ensure hospital resources remain available for people with the most serious and immediate needs.
I’m especially encouraged by the collaboration happening across healthcare. Some of the most meaningful progress occurs when nurses, physicians, advanced practice providers, pharmacists, social workers, behavioral health specialists, health plans and other experts work together around a person’s needs rather than operating in separate silos. That’s how we create a smoother experience for people and achieve better outcomes.
Beth Villena. Director of the Rehab Hospital at WakeMed Health & Hospitals (Raleigh, N.C.): Cathy’s positives are obviously my positives as well, so I’ll add just a couple of things. The pace of change related to technology development has been unmatched. Cathy and I have both been in the industry and at WakeMed for more than 30 years, and what’s happened in the last five years is exponentially more than any other previous five- or even 10-year period in our history — just seeing what’s being offered to advance rehabilitation long beyond a person’s acute episode. One thing that comes to mind is vagus nerve stimulation. That procedure has allowed stroke patients to see improvements two years and longer beyond the time of their stroke, so it’s a more distant form of post-acute care versus immediately post-discharge from an acute care setting. With that technology, there are also new revelations that it could impact an individual’s speech multiple years after a stroke. Who would have guessed five years ago that a person living with a stroke would have access to that long after? That’s what I’d add from a positive standpoint.
Nataliya Yakovleva. CEO of NYC Health + Hospitals/Coler (New York City): What excites me most is the opportunity to truly make a difference in our residents’ lives. After many years in healthcare, I am inspired by the complexity of our residents and by the incredible work our team does every day to meet their physical, emotional and behavioral health needs. At the same time, I think some of our greatest challenges are also the realities we face every day — workforce shortages, increasing medical and behavioral health needs, rising costs, Medicaid funding challenges and caring for residents who may have very limited resources or no insurance at all. These challenges can be overwhelming, but they also motivate me. I believe strongly that we have an opportunity to think differently, be creative and find new ways to deliver care while never losing sight of the person behind the diagnosis. That is what makes post-acute care so meaningful to me: knowing that the work we do can restore dignity, improve quality of life and make a real difference for people and their families.
I am incredibly excited about the continued development of our behavioral health program at Coler on Roosevelt Island. This initiative is an important step forward in our commitment to providing comprehensive, compassionate and equitable care to our residents. Behavioral health is an essential part of overall well-being, and I am proud that we are creating an environment where the emotional, psychological and social needs of our residents are recognized and addressed with the same dedication we bring to their physical health. I am especially excited about the opportunity to bring together our multidisciplinary team, strengthen our services and develop innovative approaches that support each resident as an individual. At Coler, we have a unique opportunity to make a meaningful difference in the lives of some of New York City’s most vulnerable residents, and I look forward to seeing this program grow and become an integral part of the exceptional care we provide every day.
