Reimagining Care Coordination Across the Continuum with Data and AI

Summary

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Podcast Summary: Reimagining Care Coordination Across the Continuum with Data and AI

Becker’s Healthcare Podcast
Date: March 23, 2026
Host: Lucas Voss
Guests: Robin Roberts (Director, Health IT Regulatory Affairs, PointClickCare) & Novella Thompson (Administrator, Department of Population Health, UVA Health)

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Episode Overview

This episode explores how health systems are redesigning care coordination using data and artificial intelligence (AI), especially in light of new value-based care models and the increasing demands on outcomes. With expertise from both the regulatory/tech and operational/patient care sides, the discussion centers on proactive care, persistent challenges in care transitions, the concrete impact on patients, and how AI is reshaping workflows across the care continuum.

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Key Discussion Points & Insights

1. The Shift Toward Proactive, Whole-Continuum Care

• Value-based care is driving a re-examination of care coordination beyond traditional fee-for-service models, emphasizing outcomes over transactions.
• Health systems are expanding care coordination well past hospital walls, assigning case managers upon discharge to support patients with population health programs targeting social drivers and barriers (02:00–02:35).
• Novella Thompson highlights a culture shift:
  • “Taking care of patients outside of the hospital walls positively impacts the care that we're able to provide inside our hospital and ambulatory clinic walls.” (02:45–03:20)

2. The Importance & Challenge of Seamless Transitions

• Significant improvements have been made, but breakdowns still occur, particularly during hospital discharge to post-acute care.
• Medication reconciliation and the trafficking of accurate, up-to-date patient data to skilled nursing facilities (SNFs) remain problematic (05:25–07:00).
• Small clerical errors, like transposed medication data, can have major downstream impacts.

3. Data Interoperability as a Cornerstone

• Robin Roberts comments on the evolving use of SNF EHR data:
  • “There is visibility now through and through into the skilled nursing facilities in those post acute stays, whereas previously I think it was like a black box for a lot of health systems.” (04:05–04:50)
• Even with digital records, documentation can become unwieldy, necessitating manual curation (07:35–08:10).

4. Real-World Impact: The "Orange Folder" Example

• Novella shares a striking anecdote: until recently, patients returning from SNFs to the ED often traveled with a physical orange folder containing vital information (09:00–11:00).
  • “Now I'd love for you to guess how many times that didn't show up…”
• Transition to digital solutions (e.g., integrating SNF EMR data into ED platforms) dramatically improved care and communication:
  • “It's made a huge difference in the quality of care we're providing and the quality of communication between the medical center and our SNF partners.” (10:20–11:15)

5. Artificial Intelligence: Prediction and Efficiency

• Robin highlights real-world uses of AI:

  • Predictive models for readmission/deterioration risk are now embedded into SNF EHRs, sending risk scores to hospital dashboards (12:25–12:50).
  • Real-time monitoring of patient transitions (admissions, discharges, transfers) for proactive intervention.
  • “Where the rubber is going to meet the road is the convergence of people, process, and technology.” (13:10–13:20)

• Novella sees AI’s future potential in:

  • Reducing “pyjama time” spent on after-hours clinical documentation (13:50–14:20).
  • Accurately predicting discharge dates upon admission, factoring in social drivers of health and logistical barriers.
  • “I'm looking forward to AI that helps us better predict that discharge date the day the patient is admitted, because that's really when discharge begins.” (14:25–15:20)

6. The Imperative for Partnership Across the Continuum

• Both speakers stress the necessity of strong, ongoing partnerships between hospitals, SNFs, community paramedicine, and outpatient care teams.
• Novella:
  • “We have found through a decade of service in this space that we're able to improve outcomes, ... the quality of care ... and the continuity of care for our patients while we also do the same for our inpatient, our ED, ambulatory, and post-acute care teams. It's win-win and it's a great opportunity.” (16:20–17:10)
• Robin:
  • “The future of care coordination is really about connecting the dots we've already drawn... to make those handoffs deliberate to ensure that they're visible and that there's really accountability across the episode, not just within our four walls.” (15:55–16:15)

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Notable Quotes & Memorable Moments

• On treating care transitions as opportunities:

  • Novella Thompson: “Taking care of patients outside of the hospital walls positively impacts the care that we're able to provide inside our hospital and ambulatory clinic walls.” (02:45)

• On data visibility:

  • Robin Roberts: “There is visibility now through and through into the skilled nursing facilities in those post acute stays, whereas previously I think it was like a black box for a lot of health systems.” (04:40)

• Orange folder anecdote:

  • Novella Thompson: “Now I'd love for you to guess how many times that didn't show up so that, you know, regardless of how hard we all try to do the right thing, that's just an example of how easy it is. You know, your intentions are good, the information is solid, but the way the process of hand to hand in an emergent situation can break down very easily.” (09:45–10:30)
  • “It's 2026, you wouldn't think that maybe even in 2024 we were doing that, but that's the case and it's made a huge difference...” (10:55)

• On AI, people, process, and tech:

  • Robin Roberts: “I think the other thing we have to think about is the people process in tech and the long-term partnerships and their convergence with this technology. I think that's really where the rubber is going to meet the road.” (13:10)

• On future of partnerships:

  • Novella Thompson: “Partnering with institutions and facilities ... is more important today than it ever was and must be a part of the continuum of care.” (16:25)

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Important Timestamps

• 01:52–03:30: Novella on proactive case management and outside-the-walls care
• 03:44–04:53: Robin on integrating SNF data and making discharge more transparent
• 05:19–07:17: Novella on breakdowns in medication reconciliation during transitions
• 08:55–11:15: Novella shares the “orange folder” story and its digital resolution
• 12:21–13:26: Robin on AI in predictive analytics and real-time alerts
• 13:47–15:36: Novella on AI reducing clinician workload, discharge prediction
• 15:55–17:14: Final thoughts on the future of care coordination and cross-continuum partnership

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Conclusion

This episode provides a forward-looking yet pragmatic view of care coordination in the US healthcare system. Through real stories and cutting-edge tech applications, Robin Roberts and Novella Thompson show that the future of healthcare requires not just digital tools and AI, but also integrated partnerships, culture change, and a commitment to seeing patients’ needs beyond hospital walls. Their call to action: “Connecting the dots” is essential to ensure accountability and quality across the whole episode of care.

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Transcript

[A]

Hi everyone, this is Lucas Voss with Becker's Healthcare. Thanks so much for tuning in to the Beckers Healthcare Podcast series. It's great to have you. I'm excited to welcome Robin Roberts and Novella Thompson to the podcast today. Very excited to have them. Robin is the Director of Health IT Regulatory affairs at Point Click Care where she leads innovation and certified EHR technology, interoperability and regulatory strategy for long term and post acute care. She's held leadership roles in healthcare policy, AI and national interoperability efforts and is an active contributor to industry groups including Health, the Healthcare Information and Management Systems Society, the PASU Project, and the EHR Association. So excited to have her. Novella serves as Administrator for the Department of Population Health at UVA Health, providing strategic and operational leadership across programs that support patients throughout the continuum of care. With more than 30 years of healthcare experience, she's focused on advancing high quality patient centered care beyond hospital walls. She oversees a broad population health portfolio including community paramedicine, remote patient monitor, home health, mobile care delivery, digital literacy initiatives and a value based care while partnering across UVA Health to drive care integration strategy. Novella and Robin, it's so great to have you both. Welcome to the podcast.

[B]

Thanks Lucas. Glad to be here.

[C]

Agreed. Thank you so much Lucas.

[A]

I want to hop right into the conversation because we certainly have a lot to discuss. There is a lot to discuss, especially around value based care. With value based care and reimbursement changes increasing a lot of pressure on outcomes, care coordination looks very different than it did really just a few years ago. How are health systems taking a more proactive approach today? Nobel, I'll start off with you here.

[C]

Great, thank you. Well, you're right. I mean, care coordination has evolved as we've evolved from fee for service through and continuing throughout the different models we are and have been experiencing in value based care. The exciting part of that though is that it has given us a lot of opportunities to redesign care from the ED all the way through post acute and into our ambulatory spaces. Inclusive of course, within inpatient. But today we're taking far more proactive approaches on the post acute end, which seems counterintuitive to thinking, but as soon as our patients discharge, they're assigned a case manager, a population health case manager, and they're supported through a litany of population health or post acute care programming which addresses needs around social drivers of health and understanding the barriers to health care. While we're also looking to improve the quality of care we provide by ensuring that patient needs don't drop through the cracks of a very large academic medical center. It's an exciting opportunity, it's a big lift, it's a change of culture. But the reality is taking care of patients outside of the hospital walls positively impacts the care that we're able to provide inside our hospital and ambulatory clinic walls.

[A]

And as you've mentioned, treating this as an opportunity is so crucial in approaching this. Robin, are you seeing this similarly in terms of the redesign? How are health systems taking a more proactive approach from your perspective?

[B]

Yeah, I think Novella said it best. Like at places like UVA and other hospital and health system partners, for us, we are seeing those systems want to use the SNF EHR data as part of their infrastructure because it's not just about the new cost containment and value based models to understand what's going outside of your proverbial and very literal four walls at the hospital and health system. It really is about those end to end transitions. And so as soon as Novella and the team member she's talking about have an inclination about a patient's discharge disposition, they're able to proactively follow those populations now using the longitudinal data and the record. And so they're able to follow in real times. No one's waiting for a claim or that patient to bring back into the ed. As soon as we are facilitating those handoffs and coordination, there is visibility now through and through into the skilled nursing facilities in those post acute stays, whereas previously I think it was like a black box for a lot of health systems.

[A]

Novella, coming back to what you just mentioned and what Robin just said as well, right. The opportunity and the change we're seeing, the more proactive approach certainly indicates that we have seen progress across the board, across the country. Where do you still see coordination breaking down though, particularly as patients transition into or out of that post acute care piece?

[C]

You know, the transitioning from inpatient through discharge planning and then discharge to a post acute care facility is extremely complex. Often more often than not, and there are a lot of moving pieces. You have a lot of teams working together to move a patient through this process effectively and ensure that upon discharge they have their medications, their discharged to the right place at the right time with the right care and the tools and resources they need post acute. And things can get lost in the mix and lead to issues for patients and for healthcare systems. We still find areas where we're continuously working to improve that process to ensure, even down to the smallest detail, that patient needs are met. And one of those areas that I think continues to be a focus area is ensuring not only in our emr, that the med reconciliation is correct and that the patient is leaving with the correct prescriptions and that our post acute facilities have that information and it hasn't been transposed or changed inadvertently is the greatest opportunity for continuous improvement. It's too easy to transpose a number and or not send a medication list or send an old medication list and or the in the case I'm thinking of a SNF partner receiving a medication list that has an error.

[A]

Robin now, given those challenges that Novella just outlined there in the beginning to where do you see the greatest opportunities to improve care coordination at the hospital and the snef? The skilled Nursing facility intersection.

[B]

Yeah, I think Novella called it out. Well, you know, that data is digital, but making that handoff to the snf, sometimes it's not super actionable. She brings up a great example with making sure that we have the absolutely accurate med list. But even if we think about those summary of care and discharge summaries coming with the patient, a lot of times that documentation can be bloated for the staff really. And so they're sitting there trying to take what they need, still conducting a bit of a manual curation, if you will, you know, into their workflows. And candidly, I think the other thing we see is, you know, from the hospital perspective, a single system works with numerous different SNFs. So then we have variability or you know, there's a vast spectrum of heterogeneity and how those workflows process. And when you start to stack that up, there is still just some aspects of handoff that we are working to improve.

[A]

I want to talk a little bit about the actual impact of this. Right. And we've touched on it a little bit here in our conversation. And Novella, I certainly touched on it in your introduction. You've done this for a very long time and again your goal is to support patients throughout the continuum of care. I'd love to know if you have any patient stories or examples that you could share share that sort of illustrate what we've talked about, what effective coordination looks like in practice today.

[C]

Oh, absolutely, thanks. That's a great point and opportunity to share. I look at this, the example I'm going to share is really about system partnerships and so UVA Health Medical University Medical center partners and has for, you know, six years multiple SNF facilities. And in that work with discharging our patients, many are transported by our EMT partners or paramedic partners. And I know this is going to sound very archaic, but you know, a couple of years ago, as recent as a couple of years ago, we had a partnership and a common thread of communication that if a patient needed to be returned to the hospital for a potential emergent issue or, or potentially a readmission, there was an orange folder that was put with the patient in the ambulance and then transported with the patient to the ed. Now I'd love for you to guess how many times that didn't show up so that, you know, regardless of how hard we all try to do the right thing, that's just a an example of how easy it is. You know, your intentions are good, the information is solid, but the way the process of hand to hand in an emergent situation can break down very easily. And so since since then we now, even though our ED originally pushed back, they, they just because they're so busy, they came around, took the time and understood the capabilities of the PAC management tool. And now our SNF partners put that information into their emr. That information shows up very specifically to our platform in our ed and our physicians and clinicians can provide excellent care. Removing the middleman who I'm sure was really glad to be removed in the moment and how fast paced EMT work has to be. But you know, it's 2026, you wouldn't think that maybe even in 2024 we were doing that, but that's the case and it's made a huge difference in the quality of care we're providing and the quality of communication between the medical center and our SNF partners.

[A]

Well, speaking of transporting a physical orange folder in a very busy environment, I want to talk a little bit about technology which has certainly made a difference and hopefully across most places in the US eliminated an orange folder potentially great. I want to talk a little bit about AI. I think we can't leave this conversation without not having talked about AI here. And Robin, I want to start with you here. What role is AI playing in support supporting care coordination today and where do you see the greatest near term opportunities for AI to really improve the clinical and operational workflows that we've outlined today?

[B]

Yeah, well, at point click here. I think one of the neatest uses of artificial intelligence that we have, that there's some shared visibility within the SNF in the hospital is predictive return to hospital where we're essentially looking at readmission and deterioration risk that is based on real world SNF data. And so looking at post acute encounters and predicting numerically the likelihood of readmission or ED risk and surfacing those scores in the SNF EHR into those hospital and health system dashboards. The other thing of course we're doing across the network is the monitoring the real time alerts of those admission, discharge and transfer. And so I definitely want to hear what Novella's thinking, but I just want to tie that back as we're talking about artificial intelligence and machine learning and the potential it has. I think the other thing we have to think about is the people process in tech and the long term partnerships and their convergence with this technology. I think that's really where the rubber is going to meet the road.

[A]

Yeah, it becomes an enabler for the proactive opportunity that we've touched on in our conversation. I feel like again, that's the role technology plays most of the time as an enabler. Novella, how are you seeing this? What role is AI playing in supporting care coordination today? What have you seen the, the or the greatest near term opportunity for you when you think about AI?

[C]

Well, I think it, I think it's exciting for, for, for sure and I think there are a lot of ways that it can be utilized, you know, with, with parameters in healthcare. One of the most exciting things I'm seeing and looking forward to is not only the ability to see patients and provide clinical documentation without the excess amount of time. We call it PJ time that our physicians and clinicians put into place mainly during off hours. But one of the hardest things to predict in a patient's, you know, inpatient stay is the discharge date. And try as hard as our physicians and clinician teams manage throughout the process, predicting that discharge date based on a litany of issues, mainly as, you know, social driver of health issues, whether it's caregiver support, Medicare, spend downs, needing a uai, whatever the case might be. I'm looking forward to AI that helps us better predict that discharge date the day the patient is admitted, because that's really when discharge begins. And so from that then we begin working on the barriers versus later down the line, figuring out the barriers to discharge and trying to determine how to remove those barriers while still guessing and managing through our current processes that discharge state. It's exciting to think about partnering in that space and also continuously improving our communication amongst our partners internally and externally.

[A]

Certainly more exciting than a physical folder or sending a fax.

[C]

Agreed.

[A]

Well, it's so great to have you both. I want to turn the floor over to you here as we close out our episode. Anything else you'd like to share with our audience that we haven't covered or that's important to understand here. Robin, I'll start off with you.

[B]

No, I just think that the future of care coordination is really about connecting the dots we've already drawn using the data and tools we have to make those handoffs deliberate to ensure that they're visible and that there's really accountability across the episode, not just within our four walls. And I think that the future belongs to those that are doing that.

[A]

Novella over to you.

[C]

I think one of the most important pieces is for medical centers and academic medical centers to realize that post acute care and partnering with institutions and facilities, you know, patients to address the needs in that space is more important today than it ever was and must be a part of the continuum of care. Oftentimes patients are discharged and that's that. We have found through a decade of service in this space that we're able to improve outcomes, we're able to improve the quality of care, we're able to improve the continuity of care for our patients while we also do the same for for our inpatient, our ed, ambulatory and post acute care teams. It's win, win and it's a great, like I said earlier, it's a great opportunity.

[A]

Well, Novella and Robin, again, thank you so much both for being here, sharing your insights. I also want to thank our podcast sponsor, Point Click Care, for bringing us together for this great conversation. And you can tune into more podcasts from Becker's Healthcare by visiting our podcast [e-mail].