The most expensive gap in care transitions isn’t the readmission — it’s the handoff
Care transitions are a problem everyone agrees is critical — and few believe they’ve mastered. Discharge processes are tighter, documentation is thicker and Medicare Advantage (MA) organizations have added post-discharge outreach. Still, the same scenario repeats: a member leaves the hospital, responsibility shifts, the next team starts with partial context and preventable complications emerge quickly. The biggest vulnerability isn’t the readmission metric, it’s the clinical handoff — the moment accountability changes hands while risk is still rising.
Post-acute care makes that vulnerability costly. Roughly 15% of MA beneficiaries are rehospitalized within 30 days, and rehospitalizations from skilled nursing facilities (SNFs) account for billions in spend. The estimate that 78% of SNF rehospitalizations are avoidable reframes the issue from “unlucky outcomes” to “fixable failure.”1
What tends to fail isn’t the existence of a discharge packet — it’s the absence of usable, forward-looking insight. Receiving teams often get a summary of diagnoses, procedures and medication lists without the context that drives the next decisions: functional trajectory, caregiver capacity, social instability, pending results, risk flags and what follow-up cannot wait. When that context is missing or late, clinicians are forced into rapid decisions with incomplete inputs, and the transition becomes reactive by design.
The reasons are structural. Hospitals are incentivized around throughput and operational efficiency, while plans absorb much of the downstream financial and quality impact. Post-acute providers often require preauthorization and documentation before admission, adding friction at exactly the wrong time. Members and families are asked to choose a facility as they navigate a recovery period. Accountability fragments, trust shifts and information is lost at multiple points along the transition timeline.
For MA executives, this creates a familiar tension: plans can’t “own” discharge decisions — members and families must choose — but MA executives are accountable for the outcomes that follow. Unplanned rehospitalizations increase medical spend under capitated payment, and transitions of care factor into Star Ratings, making transition reliability an enterprise issue. Meanwhile, plan outreach can be discounted at discharge because clinicians are seen as the trusted voice in the moment.
Yet plans hold an underused advantage: they can see across settings. They can spot where avoidable ED use and readmissions concentrate, which post-acute partners struggle with certain populations, and which members face compounding risk when clinical complexity and social barriers intersect. And that perspective matters more as MA’s post-acute footprint grows. Between 2021 and 2022, MA SNF admissions increased 12.1%, outpacing MA enrollment growth of 8.5%.2
The strategic shift is to target the handoff rather than the readmission. Transition investment sits downstream when the highest-impact decisions have already been made. Plans may not control discharge, but they can shape the environment through network design and performance management — defining participation requirements, steering toward high-performing sites and removing consistently poor-performing post-acute providers.
Reliability also requires standardization and shared expectations with provider partners. Aligning on what must be shared, how it will be packaged and when it must arrive becomes even more important when organizations use different, unconnected EHRs. Standardized handoff content can help receiving teams consistently see medication changes and reconciliation status, pending results, risk flags and required follow-up. It also supports earlier warning signals — such as 7-day ED visits, early readmissions, medication discrepancies resolved and follow-up completion — so breakdowns are visible while course correction is still possible.
Finally, there’s the human element: trust. Plans may increase uptake when plan insights are delivered through trusted messengers, such as hospitalists, bedside nurses and case managers, so members experience one coherent guidance pathway rather than yet another handoff. Combined with prioritizing high-risk members and concentrating intensity in the first days after discharge, this approach shifts transition management from reactive outreach to proactive reliability.
Readmissions will always be tracked, but they’re lagging indicators. The bigger opportunity is closing the clinical handoff gap so the next care setting receives timely clinical and contextual insight — and accountability doesn’t dissolve precisely when risk peaks. For payers looking for a practical starting point, read the full white paper to understand where handoffs break down and how plan leaders can strengthen post-acute transitions.
Mor V, Intrator O, Feng Z, Grabowski DC. The Revolving Door of Rehospitalization From Skilled Nursing Facilities. Health Affairs. 2010;29(1)
. Siddiqi Z. Skilled Nursing Admissions Stabilize, but Growth of Medicare Advantage Leads to 5.3% Drop in FFS. Skilled Nursing News. July 28, 2025