If you attended PALTC 2026, you heard the statistics. If you didn’t, prepare to be unsettled: 1 in 4 Medicare SNF discharges are readmitted within 30 days; 25%.
That is not a process failure. That is a systemic one. And after three days in Anaheim at PALTC26 with the country’s leading post-acute care professionals, it is clear we still have not fixed the root cause.
The Perfect Storm
Let us be honest about where we are. Medicare reimbursements continue their downward trajectory forcing SNF operators into difficult cost-cutting conversations. Meanwhile, the number of Medicare patients is increasing and expected to continue to do so significantly over the next decade. And the number of physicians in post-acute care? Expected to decrease.
The math does not work. Everyone at PALTC was discussing it
Now add the growing momentum behind Value-Based Care and the forthcoming ACO LEAD model. Medical Directors are increasingly expected to drive savings through patient-centered care models. The pressure to do more with less is not coming,it is here!
AI: Everywhere, But Not a Magic Bullet
The most attended sessions at PALTC26; anything about EHRs using AI. Scribing tools, Risk stratification algorithms,and Predictive analytics. The AI presence in healthcare is undeniable.
But here is what struck us: alongside the enthusiasm, there was genuine concern. Professionals repeatedly voiced worries about AI accuracy. They worried about the lack of regulatory frameworks. Who is accountable when an AI tool makes a mistake? These questions remain unanswered, although the common theme was that AI needed to be used in conjunction with human-based, clinical judgement.
That being the case we had multiple conversations with clinical leaders about the fact that today’s AI is based on data in the EHR, and that data is generally definitive. That is, it’s a declaration of what is, has, or will happen: a diagnosis, an order, a result, a billing claim. It entirely misses what happens in-between those declarations. And that points to a fundamental truth; there’s a lot that happens amidst the communication that guides patient outcomes. For example, a lab comes back out of range, but the RN is not clear on what to do. So she reaches out to the MD or NP for direction. A delay in response results in that lab value no longer being representative of the patient’s current status. So an order for a medication may no longer be optimal for the patient’s care. Perhaps the right order should be to retest the lab result, adding expense and further delay.
AI exclusively running on the EHR’s declarative data may be missing a big part of the equation. And inefficient communication may be further contributing to issues.
The Real Problem
AI can summarize patient data. It can flag risks. It can draft notes faster than any physician. But it cannot replace the trust, clarity, and accountability that happen when a sending nurse can reach a receiving physician in seconds. It cannot bridge the gap when a patient’s family is left wondering why no one called. It cannot solve the care transitions problem. Why? Because that problem is not technological. It is relational.
Care transitions was the recurring theme at PALTC. Data completeness and sharing across settings remain significant barriers. When communication breaks down, errors proliferate. Accountability disappears.
This is not a software problem. It is a connection problem.
The Path Forward
What separates organizations thriving under these pressures from those simply surviving? They recognize that the physician shortage is not solvable by hiring more physicians. The answer lies in giving every clinician back time. And connecting them meaningfully with the people who matter.
Smarter communication tools help. The right information routed to the right person at the right time reduces friction. It saves hours. But the most effective leaders are not just adopting new technology. They are building cultures where communication is a clinical priority. Not an afterthought.
The 1-in-4 readmission rate is not inevitable. It is a symptom. And the cure starts with closing the gap between settings, teams, and the patients we serve.
