Post-Acute Care Management Software for ACOs
PAC Management IQ is post-acute care management software for ACOs that gives care teams real-time, AI-driven intelligence on SNF stays. Follow patients from admission through safe discharge, predict and prevent readmissions, and build a high-performing SNF network that protects shared savings.
Real-Time Clinical Visibility That Lets ACOs Manage Post-Acute Care, Not Just Track It
Real-Time SNF Visibility
Follow patients into post-acute care with clinical notes, vitals, therapy, and meds, even at out-of-network SNFs. No phone tag or claims lag.
AI Readmission
Risk
Predictive Return to Hospital (pRTH) scoring flags rising risk during the SNF stay, giving teams the lead time to act before a costly readmission.
Faster, Safer Discharges
See discharge progress and post-discharge needs early so teams can remove barriers, coordinate follow-up, and get patients home sooner and safer.
SNF Network Management
Benchmark SNF partners on cost, quality, and outcomes with live performance data to build a high-performing preferred network and reduce leakage.
Everything ACO Care Teams Need to Manage Post-Acute Care
Follow patients through post-acute care and speed safe transitions
Real-Time SNF Visibility
Follow your patients into the SNF with access to clinical notes, vitals, therapy documentation, medications, and care plans, even for patients who go to out-of-network facilities. No more phone tag, no more faxes, no more waiting for claims to arrive.
Identify barriers to successful discharge
See when patients are clinically ready to transition based on real-time functional status, clinical progress, and estimated discharge dates. Spot the barriers that delay discharge so care teams can address them proactively instead of reacting after the fact.
Coordinate safer transitions home
With earlier visibility into discharge readiness and post-discharge needs, care teams can plan ahead, coordinate follow-up services, and support smoother handoffs, reducing failed transitions, excess SNF days, and downstream readmission risk.
Prevent readmissions from post-acute care with AI risk scoring
Predict and prevent rehospitalizations
AI-driven Predictive Return to Hospital (pRTH) scoring is trained on the largest senior care dataset in North America. Unlike claims-based tools that flag risk after the fact, in-stay scoring gives care teams the lead time to intervene before a hospitalization.
Prioritize caseloads by risk
Care managers can prioritize which patients need attention now based on live readmission risk, discharge readiness, and transition timing, so the most urgent patients get outreach first instead of being lost in a flat, undifferentiated worklist.
Identify contributing clinical factors
See the specific clinical factors driving elevated risk so teams can tailor outreach and coordinate meaningful interventions with SNF partners, addressing the cause rather than responding to a score with no context behind it.
Drive superior performance from your post-acute partners
Benchmark SNF partners with the Network Scorecard
Track SNF performance at a glance with built-in scorecards covering census, admissions, discharges, readmission rates, and length of stay, turning anecdotal conversations into data-driven accountability across your post-acute network.
Track performance against CMS quality metrics
Monitor SNF quality using CMS Staffing 5-Star, Health Inspection 5-Star, and rehospitalization rate, so you can steer referrals toward high-performing partners and build a preferred network on evidence rather than reputation.
Collaborate with SNFs and reduce leakage
Move from adversarial oversight to data-driven partnership using shared performance metrics. Surface utilization patterns to see where patients go post-discharge, understand leakage drivers, and steer referrals toward your strongest SNF partners.
Follow patients through post-acute care and speed safe transitions
Real-Time SNF Visibility
Follow your patients into the SNF with access to clinical notes, vitals, therapy documentation, medications, and care plans, even for patients who go to out-of-network facilities. No more phone tag, no more faxes, no more waiting for claims to arrive.
Identify barriers to successful discharge
See when patients are clinically ready to transition based on real-time functional status, clinical progress, and estimated discharge dates. Spot the barriers that delay discharge so care teams can address them proactively instead of reacting after the fact.
Coordinate safer transitions home
With earlier visibility into discharge readiness and post-discharge needs, care teams can plan ahead, coordinate follow-up services, and support smoother handoffs, reducing failed transitions, excess SNF days, and downstream readmission risk.
Prevent readmissions from post-acute care with AI risk scoring
Predict and prevent rehospitalizations
AI-driven Predictive Return to Hospital (pRTH) scoring is trained on the largest senior care dataset in North America. Unlike claims-based tools that flag risk after the fact, in-stay scoring gives care teams the lead time to intervene before a hospitalization.
Prioritize caseloads by risk
Care managers can prioritize which patients need attention now based on live readmission risk, discharge readiness, and transition timing, so the most urgent patients get outreach first instead of being lost in a flat, undifferentiated worklist.
Identify contributing clinical factors
See the specific clinical factors driving elevated risk so teams can tailor outreach and coordinate meaningful interventions with SNF partners, addressing the cause rather than responding to a score with no context behind it.
Drive superior performance from your post-acute partners
Benchmark SNF partners with the Network Scorecard
Track SNF performance at a glance with built-in scorecards covering census, admissions, discharges, readmission rates, and length of stay, turning anecdotal conversations into data-driven accountability across your post-acute network.
Track performance against CMS quality metrics
Monitor SNF quality using CMS Staffing 5-Star, Health Inspection 5-Star, and rehospitalization rate, so you can steer referrals toward high-performing partners and build a preferred network on evidence rather than reputation.
Collaborate with SNFs and reduce leakage
Move from adversarial oversight to data-driven partnership using shared performance metrics. Surface utilization patterns to see where patients go post-discharge, understand leakage drivers, and steer referrals toward your strongest SNF partners.
“PAC Management IQ helped us reduce readmissions by 28% and SNF lengths of stay by 28%, and at the same time stimulated more meaningful working relationships with our post-acute partners.”
Lori Baker
Director of Population Health Care Management and Post-Acute Network, TriHealth
28%
reduction in readmission rate (from 25% to 18%)
28%
reduction in SNF length of stay (from 25 to 18 days)
Proven Impact with PAC Management IQ
See more customer storiesTriHealth: Improved post-acute transitions and reduced readmissions with real-time data
Tandigm Health: Lifted SNF visibility above 95% and reduced readmissions by 16.7%
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TriHealth: Improved post-acute transitions and reduced readmissions with real-time data
View customer story
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Tandigm Health: Lifted SNF visibility above 95% and reduced readmissions by 16.7%
View customer story
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Request a Demo
Book a live demonstration to see how PAC Management IQ can help your ACO reduce readmissions, shorten SNF stays, and protect shared savings.
Explore More ACO Solutions
See more products for ACOsFrequently Asked Questions
It draws directly from post-acute EHRs through PointClickCare, the system of record used in more than 27,000 LTPAC providers. Instead of relying on claims lag, ADT alerts, or secondary data sources, it surfaces live clinical insight into care progression, patient status changes, and discharge readiness.
It focuses on the moments where cost and outcomes are most influenced: the SNF stay, discharge planning, and transitions between settings. By giving care teams real-time visibility into readmission risk, length of stay, and discharge readiness, it helps ACOs reduce avoidable readmissions, control post-acute utilization, and shorten SNF stays. Network performance analytics help identify facility-level cost drivers. These are the levers that directly protect shared savings.
Most approaches rely on claims data, ADT alerts, or partial data connections that show fragments of the stay. PAC Management IQ provides real-time, in-stay visibility as care unfolds because it draws directly from the system of record where SNF clinicians document care every day. ACOs get the full clinical picture, including the discharge planning context that matters most for safe, timely transitions. The Network Scorecard adds built-in SNF network management using live performance data.
It is designed to complement existing care management tools and processes. Care teams use it as a shared source of truth for post-acute patient management and coordination with SNF partners. It does not replace existing care management platforms; it adds the post-acute clinical context and continuity that most ACOs lack.
Yes. Because PointClickCare already operates inside these facilities, ACOs gain visibility across their entire post-acute network on day one, including out-of-network SNFs, with no installation and no facility-by-facility negotiation required.
Take a Closer Look
Request a demo of PAC Management IQ and see the difference real-time post-acute care management can make for your ACO.