Webinar Recap: Transforming Post-Acute Care: Leveraging Technology to Build a Collaborative Model of Care in the Home

Key Takeaways:

  • Fragmented care leads to delays, readmissions, and poor post-acute outcomes. Transitions from hospital to home require addressing clinical and non-clinical needs (such as caregiver support, transportation, and meals)
  • Technology is key to streamlining processes, connecting fragmented systems, and enabling collaboration across the care team to meet patient’s diverse needs
  • Care navigation services that mobilize human resources are crucaial for comprehensive, patient-centered care.

The topic of post-acute and home-based care is vast, and can be complex. To start off, we set the stage for this discussion with three learning outcomes our experts will focus on.

We want our audience to take away 3 main points:

  • The shift to home-based care is here and more important than ever before
  • To realize the improved patient outcomes and value in post-acute care, it takes a village
  • Technology can empower the village


1. Home-Based Care is Here to Stay

The stats are undeniable. Home-based care is on the rise, and we’re seeing these models being adopted across the board, but especially in complex conditions where patients are traditionally placed in expensive facilities can now be cared for at home.

This is a win for families, patients, providers and payers.

  1. Patients and families prefer to be at home. 80% of baby boomers continue to live in private homes and apartments rather than in institutional settings, and this will continue as 77% of adults 50+ plan to remain in their homes for the long term.
  2. In a time when the healthcare industry continues to face unprecedented staffing shortages and lower capacity for on-site care, providers are leveraging home-based models to relieve in-patient capacity constraints.
  3. Payors can drive costs down with home-based models. It doesn’t take up a hospital bed, and they no longer have to pay for 24×7 care.


A whole suite of technology solutions are powering this transition to the home.

"We're seeing these models being adopted across the board, but especially in complex conditions. where patients who may traditionally have been placed in expensive facilities, they can now be cared for and managed in the home."

2. Impact of Fragmentation

Due to broken and fragmented care coordination systems, 1 in every 3 patients experience a delay in starting their home care, sometimes waiting for weeks or months for the proper equipment. These delays compromise treatment effectiveness and recovery.

"“This issue is compounded by 1) unmanaged costs, particularly in the case of DME, where control over utilization is often lacking. This category is particularly susceptible to fraud, waste, and abuse and, 2) clinical teams deal with manual order submission processes and can't always see what’s going on with DME suppliers - all impacting how fast and accurately we can deliver care, despite everyone's best efforts.”

3. Collaboration Enables Holistic Care

Today’s disjointed home-based care system prevents members from staying healthy at home. To build effective home-based care models, we need to think of the entire health journey as a tethered ecosystem. There are many moving parts that need to align for this to be successful. Both clinical and non-clinical needs need to be addressed in order to provide a holistic and comprehensive member-centered care plan.

CMS is recognizing this with new programs like GUIDE, which ensures dementia patients and caregivers are surrounded with the right resources at the right time.

4. Addressing Care Needs in the Home

On the clinical side, members need a way to receive medication on time, the right medical equipment set up in their homes, appropriate home modifications, and more. Technology can help make sure this all happens smoothly, from streamlining the ordering process to automating prior authorization, and referrals.

On the non-clinical side, family caregivers take on the bulk of coordination and hands-on care management once patients move back into the home. From administering DME, helping to meet nutrition and hydration needs, managing critical decisions like ER visits, symptom tracking, managing end of life care decisions, and more. Our health systems and providers should recognize these caregivers as a critical, 24/7 extension of the care team in the home.

"These caregivers also influence key decisions like what post-acute facility to use. When they are integrated, they can amplify good care. When they aren’t, a lot can go wrong."

5. Technology is Critical to Making These Models Work

Technology is critical to creating a better guided and integrated experience for patients and their caregivers. It’s critical to integrate family caregivers and coordinate post-acute care in a seamless way, which improves key quality metrics while lowering utilization and costs. This drives business outcomes for payers by lowering MLR and drives revenue for providers by improving network integrity and reducing leakage out of their system.


When caregivers are aware of high-quality in-network options, they can materially reduce provider system leakage and improve network integrity. We’ve seen leakage account for 10% of health systems revenue which could be as high as $300-$500mm a year for large systems.

We can use technology to simplify, coordinate, and enable care processes in the home to more tightly integrate every piece of the puzzle. With technology, we can bring the fragmented experiences together, creating a smooth, intuitive, and seamless experience where home-based care models can succeed.

Transformative technologies will fill these practical but critical gaps most home-based care models still face, and address quality outcomes and patient/provider satisfaction.

"Technology has built a bridge between clinical and non-clinical, between hospital and home, enabling better care and outcomes. These “small” tasks used to take hours of admin time, and coordination, and were ultimately pretty manual and filled with errors. While also costing payors and members more money and headaches in the end."


Throughout the webinar, the audience sent in lots of great, thoughtful questions. Our panelists didn’t have a chance to answer each question live, so we wanted to feature some of those questions below, with answers from our experts:

What strategies do you employ to convince payors that paying for family caregiver support is of value to the payor in addition to the member?

Steven Lee: “The singular answer is with data. We shared some today, a 25% reduction in remission when the family caregiver is integrated. These are actual hard dollars that the payers have to pay when the critical care support that is needed in the home to keep the patients healthy is not happening. We’re also extremely encouraged by what CMS has done this past year with the launch of the GUIDE program. We hope and believe this will be the first of many holistic care models that will integrate the family caregiver.”

We’re seeing a proliferation of startups serving caregivers of people with Alz/dementia like Kinto, Ceresti, etc. what makes ianacare unique?

Steven Lee: “Everything in healthcare is about engagement. And so that’s been our focus since day one. If we build a solution and nobody uses it, that’s not a solution. And so we have focused very much on driving that engagement to plug the family in and to make it an ongoing part of the support. There’s a lot that goes into building that engagement.

But our solution, as I shared is a combination of the tech platform and then Bahamia’s team on the human side. And so we’ve really figured out how to compliment each other and drive engagement to each other. So the tech can drive engagement to the navigators when it’s needed. But they can also reach a navigator anytime they want. And then also the reverse, right? The navigators can drive engagement to the tech when that’s appropriate.”

Interested in learning more about how our solution can improve your post-acute program?

Book a free consultation today.

Explore related resources

RC Center Photo Tile Template (31)
To date, our caregiver support platform has supported 13,000 care teams with each pillar of support CMS has identified as critical components of care delivery in the model, including caregiver training and education.
RC Center Photo Tile Template (29)
Catch up on our latest webinar in partnership with Tomorrow Health, focused on the ways technology can empower home-based post-acute care success.
RC Center Photo Tile Template (28)
Catch up to learn more about the essential role of family caregivers, revolutionary technologies shaping quality care at home, and how technology streamlines processes, enhances patient outcomes, and transforms post-acute care.