One in five Medicare beneficiaries discharged from the hospital receive post-acute care in a skilled nursing facility (SNF), representing more than $28 billion in annual spending. Yet nearly one-quarter are rehospitalized within 30 days, making readmissions one of the most closely watched measures in post-acute care.

The implications extend far beyond a single hospital transfer. CMS's SNF Value-Based Purchasing (VBP) Program ties financial incentives and penalties to readmission rates, while the Five-Star Rating System publicly benchmarks performance across staffing, health inspections, and quality measures. Research has shown that patients receiving care in higher-rated SNFs have a lower risk of 30-day rehospitalization, underscoring the connection between quality ratings, clinical performance, and referral decisions.

As providers face growing pressure to strengthen quality measures, maintain strong ratings, and demonstrate value to referral partners, many are rethinking how they manage readmission risk. Tina Belongia, RN, BSN, Chief Clinical Officer at North Shore Health, and Kathy Derleth, RN, BSN, Customer Success Manager at Real Time Medical Systems, have seen this shift firsthand. Their experiences highlight how proactive risk management, live data analytics, and operational consistency can help SNFs improve outcomes, strengthen referral relationships, and position themselves for long-term success.

Historically, rehospitalizations were largely viewed through a clinical lens. Today, they have become a broader measure of organizational performance. Readmission rates influence reimbursement, affect publicly reported quality measures, contribute to Five-Star performance, and increasingly shape how hospitals, accountable care organizations (ACOs), and value-based care partners evaluate post-acute providers.

"Readmission performance has become a powerful indicator of overall organizational effectiveness," says Derleth. "It reflects how successfully providers are managing complex patient populations while balancing quality expectations, operational goals, and value-based care requirements."

For North Shore Health, that evolution has fundamentally changed how care teams manage rehospitalization risk across its facility network. "Our approach has evolved from primarily reacting to hospital transfers to proactively identifying and managing risk before a transfer becomes necessary," says Belongia. "Reducing readmissions remains an important clinical goal, but it is also closely tied to patient outcomes, quality measures, Five-Star performance, provider relationships, and value-based purchasing initiatives."

As referral partners place greater emphasis on outcomes, organizations that consistently reduce avoidable hospitalizations are often better positioned to strengthen both performance and credibility across the care continuum.

One of the biggest challenges in preventing hospital readmissions is recognizing clinical decline early enough to influence both the outcome and trajectory of care. Belongia notes that many hospital transfers are preceded by warning signs that emerge days before a patient ultimately requires acute care.

"A slight change in appetite, increased confusion, declining mobility, subtle respiratory symptoms, or changes in behavior may not seem significant in isolation, but collectively they can signal a patient who is beginning to deteriorate," says Belongia. “The sooner clinicians can recognize those changes, the greater their ability to intervene appropriately.”

The challenge is compounded by the sheer volume of information care teams manage every day. They are balancing clinical observations, diagnoses, medications, lab values, and provider recommendations amid growing patient acuity and complexity. Equally important, successful intervention depends on timely communication among nursing, therapy, physicians, and frontline staff, making consistency across care teams essential.

Adding to the complexity, providers have less time to identify and address risk. “The pace that patients move in and out of a facility no longer provides the luxury of extended timelines to develop and implement care strategies,” says Derleth. “In many cases, decisions need to happen within days of admission.” These care delays are particularly problematic when quality measures may not appear in traditional reporting tools until weeks or months later, limiting an organization’s ability to respond before performance is impacted.

Organizations that consistently improve rehospitalization rates treat quality management as an everyday operational discipline rather than a retrospective exercise. At North Shore Health, that includes daily risk reviews, interdisciplinary huddles, provider engagement, advance care planning discussions, and ongoing evaluation of patients requiring additional clinical attention.

"We learned that preventing avoidable hospitalizations requires more than reviewing transfers after they occur. We now focus heavily on identifying patients at risk, understanding why they are at risk, and intervening earlier,” says Belongia. "Our goal is to keep patients safely in the facility whenever clinically appropriate while delivering the level of care they want and need."

Technology has become a significant accelerator in those efforts. Using Real Time’s AI-driven data analytics platform, North Shore Health leverages live clinical intelligence to help clinicians focus attention where it is needed most, standardize decision-making, and recognize subtle changes in condition that might otherwise be missed. The platform continuously analyzes live electronic health record (HER) data, helping care teams identify patient risk earlier, prioritize interventions, and manage quality measures as part of daily operations without increasing administrative burden.

Derleth notes that high-performing SNFs use live analytics for more than monitoring outcomes. They leverage performance data across facilities to identify trends, direct education and support where it can make the most impact, all while maintaining visibility into quality, clinical, and reimbursement opportunities. In doing so, risk stratification becomes a practical tool for prioritizing interventions, directing resources, and addressing potential issues before they result in hospitalization.

Sustained improvement requires more than technology; it depends on consistent processes, accountability, and reinforcement across an organization. For North Shore Health, that meant establishing a consistent operational framework that helps care teams understand not only which measures matter, but why they matter and how they connect to patient outcomes.

"Consistency starts with creating a shared clinical framework across the organization," says Belongia. "We use standardized reports, routine audits, interdisciplinary reviews, and performance monitoring to maintain focus on high-risk patients and high-impact quality indicators.” Ongoing coaching, QAPI oversight, and education help ensure quality improvement remains part of daily operations rather than a once-a-month exercise.

Across North Shore Health's facility network, this proactive approach has contributed to measurable improvements in value-based care outcomes, including a nearly 20 percent reduction in return-to-hospital rates, higher overall Five-Star ratings, and improved results across key quality measures. One of North Shore Health’s biggest lessons has been that sustainable improvement requires more than data alone. "Technology identifies risk, but people prevent hospitalizations,” says Belongia. “The organizations that are most successful do not rely on technology alone. They create reliable processes around the data.”

Derleth believes the highest-performing SNFs will be those that successfully combine strong clinical practices with real-time data analytics, enabling care teams to respond faster, manage increasing acuity more effectively, and support stronger outcomes as expectations continue to evolve.

The providers best positioned for long-term success will be those that move beyond measuring performance and build sustainable processes for managing risk, improving quality, and preventing avoidable hospitalizations before they occur.

Belongia and Derleth will expand on these strategies and lessons learned during their AHCA/NCAL Conference & Expo session, Readmission Risk & Enhanced Quality: SNF's Strategic Role, this October.

For more information, visit www.realtimemed.com.