The Real Deal on Interoperability in Post-Acute Care

It wasn’t that long ago when post-acute providers had to rely on faxes, follow-up phone calls and crossed fingers to get the patient data they needed. But that’s finally starting to change and not by accident. For years, skilled nursing facilities, therapy clinics, assisted living centers and others in the post-acute world were sitting on the interoperability sidelines. Why? As with electronic health record adoption initiatives, all funding and priorities were placed on health systems and acute hospital settings.That meant even well-intentioned efforts to connect systems often hit brick walls. The hospital had the patient’s chart, the SNF needed it, but unless the systems could talk, someone was printing it out and handing it over. Or worse, faxing it.

TEFCA Changes the Game

That frustrating disconnect between hospitals and post-acute care is finally getting fixed. TEFCA, which stands for Trusted Exchange Framework and Common Agreement, stepped in with the structure. Contracts were signed. Rules were set. The federal government gave it the go-ahead. Now more than 150,000 post-acute providers are joining national networks. That includes therapy clinics, skilled nursing facilities, home health agencies and senior living communities. For the first time, they’re getting access to clinical data the way hospitals have had for years.

This shift came into focus on a recent episode of InnovaHealth’s podcast. Luis Montes sat down with Teresa Bell to talk through what’s actually changing. Teresa’s been deep in the world of interoperability for years. If you’ve heard of Carequality, CommonWell or TEFCA, there’s a good chance she helped shape it.

Yes, It’s Live. Yes, It Works.

If you’re in post-acute care, chances are you don’t have to wait. Real-time hospital records like medications, allergies and care notes can already be pulled straight into your EHR. No more phone tags and no more miscellaneous faxes clogging up your desk.

Is it flawless? Not yet. Some documents from post-acute still get dumped into catch-all folders. But Teresa pointed out that it’s getting better. Smarter directories, new document types and some solid user training are already smoothing things out.

Direct Messaging Gets Smarter

Direct messaging used to feel like sending a secure email from one provider to another. Now, it’s much more efficient. Facilities can route referrals directly to the right team. Messages are structured, trackable and fully integrated into clinical workflows. Teresa shared how some organizations are wrapping smart data into those messages so they’re not only faster but more complete. That means fewer missed details and fewer follow-up calls.

Meet the Network Behind the Curtain

This new shift is being powered by QHINs, or Qualified Health Information Networks. If the healthcare system had cell carriers, QHINs would be it. You choose one, and your EHR can reach everyone else in the network. It turns your system just from a record warehouse to a smart and connected device. Behind the scenes, QHINs are doing the heavy lifting by quietly making the data flow. And it’s not just hospitals and providers anymore, federal agencies like CMS, CDC and the VA are already on board. This isn’t just another policy to memorize, TEFCA has become the real infrastructure that’s replacing all those faxes and fragmented handoffs. Even patients are getting in on it. With the right app, they can request their records from across the country, no middleman required.

So What Does That Mean for You?

If you’re a therapist or nurse at a skilled nursing facility, you can stop chasing data. The information is available real time, right inside your system if your EHR is connected. Want in? Talk to your vendor. If they’re not connected to a QHIN, ask why not. Larger chains can also connect referral platforms like Salesforce to QHINs, pulling in patient data before the referral even hits the clinical team. There’s flexibility now to build smarter workflows and even apply AI to surface the right data at the right moment. Luis and Teresa both pointed to the same takeaway that this isn’t a future-state conversation anymore. It’s happening now. National data exchange for post-acute care isn’t a possibility but a reality. And the post-acute world is finally in the loop.

This blog only scratches the surface. To hear how the pieces came together and where things are headed next, check out the full podcast episode from Innova Health where Teresa and Luis discuss the details that are transforming how care gets delivered across the continuum.