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The days and weeks following a hospital stay are some of the most vulnerable in a patient’s care journey. Despite being a focus of health systems and policymakers alike, readmissions still represent a major clinical risk and source of financial pressure with 15% of hospital-wide discharges resulting in an unplanned readmission within 30 days. Getting the transition right is no longer optional; it’s a performance lever.

What Is Post-Acute Transitional Care?

Post-acute transitional care solutions help providers manage the critical handoff after an acute episode—ensuring patients safely transition to home, SNFs, or other settings. These tools reduce readmissions and close care gaps by structuring proactive follow-up and communication. They’re typically used by discharge planners, care managers, and transitional care teams to track recovery and flag emerging risks. There is some overlap with care team coordination solutions, which we’ll break down below. 

How the Technology Works

Most platforms combine a few core functions:

• Automated outreach via SMS, phone, or portal-based tools to check in with patients after discharge and flag concerns or confirm recovery milestones.
  

• Care plan reinforcement to clarify meds, appointments, or next steps
  

• Risk stratification—based on comorbidities, discharge disposition, or social determinants—to identify patients who need closer follow-up.
  

• Cross-setting coordination across hospitals, SNFs, PCPs, and home health providers to ensure smooth transitions.
  

• Task management and alerts to assign, escalate, and close the loop on follow-ups.

The best solutions move beyond check-the-box workflows, offering flexible outreach, real-time visibility, and actionable alerts that surface issues early.

Vendor Landscape

Vendors tend to fall into two groups:

Purpose-Built Transitional Care Platforms

These tools are built specifically for post-acute handoffs, with focused workflows for reducing readmissions and managing high-risk discharges. Examples: About Healthcare, Aidin, DischargeHealth, Evolv Health, Kandu Health, NexusConnexions, Olio, Rovicare.

Why choose one? You’re solving a specific problem (e.g. understanding capacity constraints for in-network SNFs for upcoming discharges), want fast time to value with prebuilt workflows, or need to routinely coordinate across a broad network of external providers (such as ACOs or health systems with broad networks).

Broader Care Coordination Platforms with Transitional Care Features

These platforms support a range of care management use cases—chronic care, population health, RPM—and include transitional care as one workflow among many. Examples: CareVitality, Dina, HealthArc, HealthViewX, NetSmart Care Coordination, Smartlink Health, Thoroughcare, and WellSky CarePort. 

Why choose one? You want one platform for multiple programs, prioritize tight EHR integration, or have resource constraints that make it preferable to maintain and train staff on a single system.

Where the Market Is Going

Despite the clear value prop, adoption of transitional care platforms remains uneven. Technology alone doesn’t drive adoption—policy and payment do. Uncertainty around the future of CMS’s Hospital at Home waiver, along with broader regulatory unpredictability, has made health systems wary of investing in long-term care infrastructure. Providers are hesitant to commit to new care models without stable reimbursement and clear regulatory signals.

Looking ahead, the biggest opportunity for transitional care platforms may not be just in better software—but in aligning with the next generation of care delivery models. If the right policy frameworks emerge, these tools could become the operational backbone of hospital-at-home programs, longitudinal care coordination, and risk-bearing primary care. Until then, growth will depend on whether vendors can deliver enough value—in outcomes and operations—to overcome inertia in a shifting policy landscape.