Public Health Strategies for Post-Acute Support

1. Transitional Care Programs

• Ensure seamless handoffs between hospital, rehab, and community care.
• Utilize nurse case managers, pharmacists, or social workers to coordinate follow-up, medication reconciliation, and care plans.
• Proven to reduce 30-day readmissions (Coleman et al., 2006; CMS CCTP evaluations).
• Example: The Care Transitions Intervention (CTI) and Transitional Care Model (TCM).

2. Home- and Community-Based Services (HCBS)

• Provide in-home nursing, therapy, or personal care services for post-discharge patients—especially elderly or disabled populations.
• Often coordinated through Medicaid waivers or Area Agencies on Aging.
• Shown to reduce nursing home admissions and emergency department use.

3. Digital & Remote Monitoring

• Use of telehealth, remote patient monitoring (e.g., for heart failure, diabetes), and mobile apps to track symptoms and adherence.
• Increases early detection of complications and fosters patient engagement.
• Public health relevance: Expands access, particularly in rural or underserved areas.

4. Community Health Worker (CHW) Programs

• CHWs bridge the gap between clinical care and community support—especially in disadvantaged populations.
• Support includes medication coaching, appointment reminders, housing/food navigation.
• CHW-led programs have reduced 30-day hospital use and improved chronic disease management.

5. Behavioral Health & Social Support Integration

• Screening and referral for mental health, substance use, housing, food, and financial insecurity post-discharge.
• Integration with programs like 988, supportive housing, peer support networks, and local behavioral health clinics.
• Addressing social determinants post-discharge is a CDC-recommended strategy to prevent relapse and reduce avoidable acute care use.

6. Peer Recovery and Navigation Programs

• Peer coaches or recovery navigators provide ongoing emotional and practical support to individuals recovering from serious illness, trauma, or addiction.
• Often part of trauma-informed or behavioral health-informed discharge planning.
• Can be deployed through community organizations or health departments.

7. Population Health Dashboards & Surveillance

• Health systems and public health agencies use risk stratification tools and readmission surveillance to target support proactively.
• Identifies high-risk patients (e.g., those with multiple comorbidities, recent falls, or behavioral health needs) for follow-up.

Key Takeaway

Public health post-acute strategies focus on continuity, equity, and social support—bridging hospital discharge and long-term health with community services, technology, and cross-sector partnerships. These approaches align with CMS value-based care goals and global best practices for reducing unnecessary hospital use and promoting patient recovery.