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Optimizing Care Transitions with Cross-Setting Alignment & Real-Time Data Sharing
Points of Light 2026 Case Study 1
Author
Mac Boyter
Author
Aurene Wilford
Faith-Based Risk-Bearing Health System 1, Healthcare Organization 1, and PointClickCare addressed major post–acute care visibility gaps by standardizing care-transition workflows and enabling real-time clinical data sharing through PointClickCare’s PAC Management and an AI-driven discharge tool. These tools replaced manual, reactive processes with automated alerts, daily risk scoring, and integrated discharge workflows, improving coordination across acute care, SNF, and ambulatory care teams. The collaboration reduced administrative burden, lowered total cost of care, and decreased ED visits and SNF readmissions. Faith-Based Risk-Bearing Health System 1 achieved annual shared savings, consistently ranked in the top national quartile for readmission metrics, and expanded their post–acute care network while strengthening partnerships among payer organizations, healthcare organizations, and SNFs.
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Key Findings:
- Executive Summary
- The Collaborators
- Points of Friction—Challenges to Be Solved
- Action Plan—How the Collaborators Worked Together to Reduce Friction
- Points of Light—Outcomes Achieved Through Collaboration
- Lessons Learned—What Best Practices Can Other Organizations Replicate?
- What's Next?—Vision for the Future
Project Manager
Joel Sanchez
This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2026 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.