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Policymaking, Regulation, & Strategy

Long-Term & Post-Acute Care

Why Focus Health IT on Care Transitions?

Patients who receive long-term & post-acute (LTPAC) services typically have co-occurring health conditions, such as diabetes or high blood pressure. These patients are likely to encounter multiple care settings, requiring ongoing communication to and from each service point. During a roundtable [PDF - 377 KB] event in July 2012, a group of LTPAC stakeholders identified care transitions as a central focus., Health information technology (health IT) provides an opportunity for health care providers to share health information in a timely and secure manner across care settings to support patient-centered care, particularly during transitions from one care setting to another. When multiple physicians are treating a patient following a hospital discharge, information about the patient’s care is missing 78% of the time.1 Innovations in health IT can facilitate transitions across provider settings and ultimately improve the health outcomes for this patient demographic and reduce cost to the health care system.

How are LTPAC Providers Using Health IT Today?

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides monetary incentives and technical assistance to help eligible providers use certified technology to become meaningful users of electronic health records (EHR). The Office of the National Coordinator for Health Information Technology (ONC) establishes the standards and certification criteria to ensure that EHR technology is capable of meeting certain minimum requirements. 

Since HITECH’s enactment, adoption of basic EHR systems by office-based physicians grew by over 80% between 2009 and 2012. Stage 2 of the EHR Incentive Program will take an important first step in supporting the needs of persons who receive LTPAC services by requiring eligible providers to send care summaries during transitions of care, which may include LTPAC providers. As EHR adoption and interoperability requirements continue to advance in the acute care and ambulatory care sector, it will be increasingly important for LTPAC providers to adopt EHRs that have the capability of exchanging standardized clinical data with care partners.2

Although LTPAC providers are not eligible for incentive payments under the HITECH Act, innovative examples of health IT in LTPAC are beginning to emerge.  For example, ONC awarded Challenge Grants to encourage health information exchange and interoperability. Among the grantees, four states, MA, MD, OK and CO, have focused their work on improving care transitions specific to long-term & post-acute health care settings.

ONC also supported the Beacon Community program to accelerate the role of health IT in local health caresystems and equip them with the tools and resources needed to achieve higher levels of health care quality and efficiency. The Beacon Program provided $250 Million in funding to support 17 communities. The Keystone Beacon Community leveraged health IT by developing an innovative, secure, low cost tool  to allow nursing facilities and home health agencies, with or without an EHR, to share patient information electronically with other long term care facilities, hospitals or physician practices.

In addition to grant programs, ONC continues to support LTPAC through Standards and Interoperability (S&I) initiatives. The S&I Longitudinal Coordination of Care (LCC) Workgroup (WG)  has made significant progress in the identification of standards that support and advance interoperable health information exchange, including care plan exchange and transfer of care datasets.

What Does this Mean for the LTPAC Community?

The population of those aged 65 and older will more than double from 40 million to 89 million by 2050. As the U.S. population ages the demand for LTPAC services are expected to grow.  While LTPAC services are generally attributed to the elderly, these services also include younger persons with disabilities. LTPAC services cover a wide array of services ranging from institutional services provided in specialty hospitals and nursing homes, to a variety of home and community based services. Transitions across acute, post-acute, and long-term care settings are common and can be costly. Additionally, one study found 60% of medication errors occur during times of transition.3

These errors may result in readmissions to the hospital and excessive use of emergency, post-acute, and ambulatory services. Implementing mechanisms to prevent medication errors and limit duplicative services is a function that health IT has been designed to address. To find more information on the benefits of health IT for LTPAC providers please view the LTPAC Issue Brief [PDF - 3.2 MB].


  1. Van Walraven, C., Seth, R., Austin, P. & Laupacis, A., 2002. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med, Volume 17, pp. 186-92.
  2. Health IT in Long-Term & Post-Acute Care Issue Brief
  3. JD Rozich & RK Resar, Medication Safety: One Organization’s Approach to the Challenge, J. Clin. Outcomes Manag. 8:27-34 (2001).