| The Untapped Role of Rehabilitation in Skilled Nursing Facilities | <p><img src="/Articles/PublishingImages/740%20x%20740/therapy_3.jpg" alt="seniros in therapy" class="ms-rtePosition-2" style="margin:5px;width:463px;height:324px;" />Rehabilitation is often viewed as a department within a skilled nursing facility. But its greatest value may extend far beyond the therapy gym into fall prevention, nursing collaboration, functional decline, discharge readiness, staff education and everyday resident care.</p><p>For decades, rehabilitation in skilled nursing facilities has been closely associated with the therapy gym: evaluations, treatment sessions, functional goals, and discharge planning. Those responsibilities remain central to rehabilitation practice, but they represent only part of what a strong rehabilitation program can contribute to a skilled nursing organization.</p><h3>Looking Beyond the Therapy Gym</h3><p>A resident's ability to transfer affects nursing care and staff workload. Walking ability influences fall risk and participation in daily activities. Positioning can affect comfort and skin integrity. Cognitive and communication abilities influence safety and caregiver education. Functional progress or decline can significantly affect discharge planning.</p><p>Consider a resident who begins requiring more assistance with transfers. On the surface, it may appear to be a rehabilitation concern. That change can affect toileting, fall risk, nursing workload, skin integrity, dining, activities, and discharge potential. Recognizing the change early gives the interdisciplinary team an opportunity to respond before a small functional decline becomes a larger clinical challenge. That is the rehabilitation ripple effect: one change in function can influence multiple aspects of resident care.</p><h3>The DOR as a Resource</h3><p>This broader approach also changes how organizations can view the director of rehabilitation (DOR). Traditionally, DOR responsibilities have centered on therapy operations such as staffing, scheduling, productivity, documentation, compliance, and clinical outcomes. Those responsibilities remain important, but rehab leadership can extend beyond managing the therapy department.</p><p>One of the simplest ways to begin is to give the DOR a consistent seat at the interdisciplinary table. Rehabilitation leadership can contribute to clinical meetings, fall reviews, discharge planning, risk-management discussions, and other conversations where function may influence outcomes. The purpose is not to make rehabilitation responsible for every clinical issue. It is to ensure that functional expertise is available when decisions are being made.</p><h3>Making Functional Decline an Early Warning</h3><p>Skilled nursing facilities routinely monitor changes in condition, but functional change deserves similar attention. A meaningful decline in walking, transfers, self-care, cognition, or endurance may be an early sign that something has changed. Instead of waiting for that change to contribute to a fall, hospitalization, or significant loss of independence, facilities can use functional decline as an interdisciplinary trigger for communication.</p><h3><img src="/Articles/PublishingImages/740%20x%20740/fall_risk.jpg" alt="fall risk" class="ms-rtePosition-2" style="margin:5px;width:240px;height:240px;" />Bringing Rehabilitation into Fall Prevention</h3><p>Falls offer another example of how rehabilitation expertise can support facility-wide goals. A fall should not automatically result in a therapy referral. However, rehabilitation can bring a valuable functional perspective to interdisciplinary fall reviews.<br></p><ul><li>Was there a change in balance? </li><li>Did transfer ability decline? </li><li>Is the resident using the appropriate device? </li><li>Has wheelchair positioning changed? </li><li>Is cognition affecting safety awareness? </li><li>Does the resident have the physical ability to perform what he or she is attempting to do? </li></ul><p>These questions can help the team move beyond simply adding another intervention after each fall. The goal is to understand why the resident fell and what functional factors may have contributed.</p><h3>Starting Discharge Planning Earlier</h3><p>Rehabilitation also has an important role in helping facilities move from a "discharge date" mindset to a discharge readiness mindset. Planning should not begin a few days before a resident leaves. Therapy can help identify equipment needs, caregiver training requirements, mobility barriers, and environmental concerns early in the stay. Those findings can then be shared with nursing, social services, and families while there is still time to address them. Whenever possible, rehabilitation should also extend beyond the controlled environment of the therapy gym.</p><p>Practicing bathroom mobility, uneven surfaces, community access, caregiver-assisted tasks, and other real-life challenges may reveal barriers that are not obvious during a routine treatment session. A resident's ability to walk 100 feet in a hallway is useful information.  The goal is for them to function safely and meaningfully in real life.</p><h3>10 Ways Any SNF Can Strengthen Rehabilitation Collaboration</h3><p>None of this requires an elaborate new program. Many facilities can begin by strengthening systems and conversations that already exist.</p><p>Ten practical starting points include:<br></p><ol><li>Give the DOR a consistent role at the interdisciplinary table for clinical, operational, discharge, and quality discussions where function matters.</li><li> Include rehabilitation in interdisciplinary fall reviews when mobility, balance, cognition, transfers, positioning, or equipment may be contributing factors.</li><li>Create an accessible system for communicating functional levels, so nurses and CNAs understand residents' current transfer and mobility recommendations.</li><li>Strengthen the therapy-restorative nursing connection to support continuity as residents transition from skilled therapy.</li><li>Treat meaningful functional decline as an interdisciplinary trigger for communication and clinical review, recognizing that changes in function may signal a broader change in the resident's condition.</li><li>Use therapists as frontline educators through brief, practical teaching on transfers, positioning, mobility, and supporting resident independence.</li><li>Bring rehabilitation into discharge planning early, rather than waiting until the discharge date approaches.</li><li>Practice real-life functional challenges, not only tasks performed within the therapy gym. Person-centered functional training can help the interdisciplinary team identify barriers that might otherwise emerge only after discharge.</li><li>Review facility outcomes collaboratively, asking where mobility, cognition, and functional status may be contributing.</li><li>Ask one simple question during leadership discussions: "Where can rehabilitation help?"</li></ol><p>That final question may be the most important. Not every problem needs a therapy solution. But routinely asking the question encourages leaders to see rehabilitation as a clinical resource rather than an isolated department.</p><h3>The Next Evolution of Rehabilitation</h3><p>PDPM changed the relationship between rehabilitation utilization and reimbursement in skilled nursing. The next evolution may be less about payment methodology and more about organizational culture. Facilities should continue asking whether therapy is producing meaningful outcomes for individual residents. But perhaps skilled nursing leaders should ask another question as well:<br></p><ul><li>Is rehabilitation helping the entire facility become more functional?</li><li>Is it helping staff understand mobility?</li><li>Is it identifying functional decline earlier?</li><li>Is it supporting fall prevention?</li><li>Is it strengthening restorative nursing?</li><li>Is it preparing residents and families for discharge?</li><li>Is it helping residents maintain as much independence as possible throughout the day, not just during therapy?</li></ul><p><img src="/Articles/PublishingImages/2026/Pradeepika-Samagh.jpg" alt="Pradeepika Samagh" class="ms-rtePosition-2" style="margin:5px;" />When the answer is yes, rehabilitation is doing more than providing treatment.</p><p>It contributes clinical insight, functional expertise, staff education, and interdisciplinary support to the organization as a whole. For skilled nursing leaders facing increasingly complex residents and increasingly complex operational challenges, that may be one of the most underutilized resources already inside the building.</p><p>What happens in the therapy gym rarely stays in the therapy gym. The greater opportunity is recognizing just how far that impact can reach.<br><br><em>Pradeepika Samagh, PT, DPT, MBA, CFPS, CCI, LNHA, RAC-CT, is director of rehabilitation and physical therapist at Auburn Oaks Care Center in Auburn, California. Her professional interests include rehabilitation leadership, interdisciplinary collaboration, fall prevention, functional outcomes, and expanding rehabilitation’s role as a clinical partner in post-acute and long term care.</em></p><p><em><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#212121;">Provider<em> magazine includes information from a variety of sources, such as contributing experts. The views expressed by external contributors do not necessarily reflect the views of Provider magazine and AHCA/NCAL.<span class="Apple-converted-space"> </span></em></span><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#96607d;"><a href="/About/Pages/Submit-Article.aspx" target="_blank" title="https://www.providermagazine.com/About/Pages/Submit-Article.aspx" data-outlook-id="badae440-b0ce-4219-9c08-f7e349a8e3d6" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="color:#96607d;margin-top:0px;margin-bottom:0px;"><em><span style="text-decoration:underline;">Learn how to submit an article.</span></em></a></span><br></em></p> | 2026-10-01T04:00:00Z | <img alt="rehab" src="/Articles/PublishingImages/740%20x%20740/senior_woman_exercise_2.jpg" style="BORDER:0px solid;" /> | Caregiving;Falls | Pradeepika Samagh | Rehabilitation is often viewed as a department within a skilled nursing facility. But its greatest value may extend far beyond the therapy gym into fall prevention, nursing collaboration, functional decline, discharge readiness, staff education and everyday resident care. |
| Removing the Transportation Barrier to Employment in Nebraska | <p style="text-align:center;"><img src="/Articles/PublishingImages/2026/The%20Heritage%20at%20Legacy.jpg" alt="Ther Heritage at Legacy" style="margin:5px;width:500px;height:333px;" /> </p><p><br></p><p>Since launching in January 2026, the Nebraska Health Care Foundation’s Cars for Caregivers program has awarded four vehicles to employees who lacked reliable transportation to work. In a largely rural state, transportation can be a significant barrier to employment.</p><p>The program is one of several unconventional workforce solutions developed collaboratively by the Nebraska Health Care Association (NHCA) and its foundation. The Foundation conducts the initial application and vetting process before referring eligible applicants to Chariots4Hope, a Nebraska-based nonprofit that has spent the past 10 years helping people overcome transportation barriers through a network of more than 100 referral organizations. Chariots4Hope completes the additional review, vehicle placement, and participant education.</p><p>“We don’t just hand someone the keys and send them on their way,” said Jason Hurt, who founded Chariots4Hope with his wife, Michelle. “We provide classes on maintaining a vehicle, insurance, driving, and other responsibilities of car ownership, and we want participants to know we’re invested in their long-term success.”</p><p style="text-align:center;"><span><img src="/Articles/PublishingImages/2026/Hillcrest-Grand-Lodge.jpg" alt="Hillcrest Grand Lodge" style="margin:5px;width:500px;height:333px;" /></span> </p><p>“Those who work in Nebraska’s nursing homes and assisted living communities are incredibly dedicated and show up every day because they know their residents are counting on them,” said Jalene Carpenter, president and CEO of the Nebraska Health Care Association. “We created Cars for Caregivers after hearing transportation was a barrier for staff, and we wanted to find a practical way to help people stay in the workforce while supporting their own families.”</p><p>Cars for Caregivers is made possible by individuals and organizations that donate vehicles and funds. Donors include NHCA provider and vendor members, as well as members of the public. Vehicles do not need to be operable. Nine vehicles have been donated since the program launched, and the four recipients to date have benefited through a variety of arrangements, including proceeds from vehicle sales, scrap value, and, in one case, the donor vehicle itself.</p><p><span><img src="/Articles/PublishingImages/2026/Tracy-Rathe.jpg" alt="Tracy Rathe" class="ms-rtePosition-2" style="margin:5px;width:150px;height:184px;" /></span>The program offers a different way to approach workforce retention: identify a practical barrier keeping someone from work and find a creative way to remove it.</p><p><em>Tracy Rathe is senior vice president of strategic initiatives at the Nebraska Health Care Association. She also leads the Nebraska Health Care Foundation’s mission to attract, develop, and retain the workforce serving Nebraska’s nursing homes and assisted living communities through innovative initiatives.</em></p><p><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#212121;"><em>Prov</em><em>ider</em><em> magazine includes information from a variety of sources, such as contributing experts. The views expressed by external contributors do not necessarily reflect the views of Provi</em><em>der magazine and AHCA/NCAL.</em><span class="Apple-converted-space"> </span></span><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#96607d;"><a href="/About/Pages/Submit-Article.aspx" target="_blank" title="https://www.providermagazine.com/About/Pages/Submit-Article.aspx" data-outlook-id="badae440-b0ce-4219-9c08-f7e349a8e3d6" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="color:#96607d;margin-top:0px;margin-bottom:0px;"><span style="text-decoration:underline;"><em>Learn how to submit an article.</em></span></a></span><br></p> | 2026-10-01T04:00:00Z | <img alt="Cars for Caregivers" src="/Articles/PublishingImages/2026/cars.jpg" style="BORDER:0px solid;" /> | Caregiving | Tracy Rathe | Since launching in January 2026, the Nebraska Health Care Foundation’s Cars for Caregivers program has awarded four vehicles to employees who lacked reliable transportation to work. |
| The Basics of Conducting a SWOT Analysis | <p><img src="/Articles/PublishingImages/2026/swot_r.jpg" alt="SWOT" class="ms-rtePosition-2" style="margin:5px;width:350px;height:350px;" />Years ago, when I first began my career as a long term administrator, one of my close friends and mentor taught me the importance of strategic planning. He told me that each time he accepted a new administrator position, one of the first things he did was conduct a SWOT analysis. He felt this was important in getting a current, accurate, and clear picture of the facility in establishing direction and focus for his facility. This was a very valuable business lesson that can be applied in any organization including long term care.</p><p>As I began using this process myself, I came to understand more fully why he used it. The process is transparent and gives clarity to many aspects of your facility position and operation. I found that what my friend and mentor taught me was true and useful.</p><h3>SWOT as First Step in Strategic Planning</h3><p>There has been much that has been written about conducting a SWOT Analysis. Even though this information has been written about in depth, I have always followed basic business principles and practices that I learned about in college, training, and experience. In my opinion, conducting a SWOT analysis is the first step in strategic planning. This process begins to lay out your road map in setting direction for your facility. This SWOT analysis provides a basis for establishing operating goals, budgets (operating and capital) and in meeting and forming key performance indicators (KPI). </p><p>I have included below a sample of a SWOT analysis that I conducted a few years ago with my management team as a reference.</p><h3>Conducting a SWOT Analysis</h3><p>With all this in mind, let’s take a closer look at what a SWOT Analysis would look like. SWOT is an acronym for strengths, weaknesses, opportunities, and threats. It’s a basic business tool used for strategic planning and to identify your facility’s strengths, weaknesses, threats, and opportunities. It helps your management team see your facility as it truly is—its capabilities, vulnerabilities, and opportunities—so decisions become more focused, more defensible, and more aligned with resident needs and regulatory expectations. The benefits would include, but are not limited to some of the following areas:<br></p><ol><li>It strengthens regulatory and survey readiness.</li><li>It provides for better and more focused operational decisions.</li><li>It improves quality of care and resident outcomes.</li><li>It enhances workforce stability and competency.</li><li>It supports financial sustainability and viability.</li><li>It clarifies your competitive position.</li><li>It aligns your management team, staff, and stakeholders (residents and family members).</li><li>It drives a more focused strategic plan.</li><li>It integrates with your QAPI and facility assessment.</li><li>It helps your management team anticipate future challenges.</li><li>It identifies future capital improvement needs, new programs, or services. </li><li>It gives you the clarity and current position of your facility to do more effective planning.</li></ol><p><strong>1. Assemble the Right Interdisciplinary Team</strong><br>A SWOT analysis only works when you have your full management team present. This will ensure a broad perspective by your entire team, reflect the realities of your facility, and allow everyone to participate and have input. It will also be transparent and build trust with your team. They include:<br></p><ul><li>Administrator</li><li>Director of Nursing</li><li>MDS Coordinator</li><li>Infection Preventionist</li><li>Assistant Director of Nursing</li><li>Staff Development Coordinator</li><li>Human Resources Manager</li><li>Rehab Director</li><li>Activities Director</li><li>Business Office Manager</li><li>Admissions Director</li><li>Social Services</li><li>Dietary Manager</li><li>Environmental Services (Housekeeping, Maintenance, and Laundry Supervisors)</li><li>Medical Director (if available)</li><li>QAPI Coordinator</li></ul><p><strong>2. Gather Objective Data Before the Meeting</strong><br>A SWOT analysis should be based in facts, not opinions. This gives your SWOT analysis more credibility. There are numerous documents, reports, etc. that you will want to obtain ahead of time and use as a resource when you are analyzing various aspects of your facility operation. These documents include, but are not limited to the following items:<br></p><ul><li>Survey history (deficiencies, trends, repeat tags)</li><li>Quality Measures and Five Star ratings</li><li>Staffing data (turnover, agency use, RN coverage)</li><li>Clinical outcomes (falls, pressure injuries, infections, rehospitalizations)</li><li>Financial reports (payer mix, revenue trends, cost pressures)</li><li>Facility Assessment (42 CFR §483.70(e))</li><li>Competitor analysis (local SNFs, hospital partnerships, specialty programs)</li><li>Market trends (acuity changes, managed care penetration)</li><li>Previous strategic plans and operating goals</li></ul><p><strong>3. Identify Strengths</strong><br>In looking at your strengths, focus on internal capabilities that give your facility an advantage. What do you do really well? It’s important to look at all areas of your facility that are perceived as strengths by your team. Ask: What do we do better than others? What are our proven competencies? Some examples include:<br></p><ul><li>Strong infection control program</li><li>High therapy outcomes</li><li>Stable leadership team</li><li>Low turnover in key departments</li><li>Strong hospital relationships</li><li>High resident/family satisfaction</li></ul><p><strong>4. Identify Weaknesses</strong><br>These are internal vulnerabilities or operational areas that hinder or are limiting the facility’s performance or compliance. Ask: Where do we struggle? What repeatedly causes problems? Ultimately, your goal should be to focus on converting any identified weaknesses into strengths. Examples include, but are not limited to the following areas:<br></p><ul><li>High employee turnover</li><li>Overreliance on agency</li><li>Gaps in staff competencies</li><li>Poor communication and teamwork between departments</li><li>Aging equipment or limited technology</li><li>Low census or occupancy</li><li>Cost control</li><li>Poor quality of care outcomes</li><li>History of poor regulatory compliance</li></ul><p><strong>5. Identify Opportunities</strong><br>These are external factors the facility can leverage or capitalize on. Again, ask questions about what external trends could benefit our facility? Some examples include:<br></p><ul><li>New hospital partnerships or managed care contracts</li><li>Growing need for short term rehabilitation</li><li>Behavioral health program expansion</li><li>Telehealth reimbursement</li><li>Community outreach programs</li><li>Grants or funding opportunities</li></ul><p><strong>6. Identify Threats</strong><br>These are external risks that could negatively impact the facility. Ask: What external forces could harm us if we don’t prepare? A few examples include: <br></p><ul><li>Competitors adding specialty programs</li><li>CMS reimbursement changes</li><li>Workforce shortages</li><li>Litigation trends</li><li>Increasing resident acuity</li><li>Regulatory changes</li><li>New competitor facility being built</li></ul><p><strong>7. Prioritize the Findings</strong><br>Not all SWOT items matter equally. Rank each item by:<br></p><ul><li>Impact (high, medium, low)</li><li>Urgency</li><li>Feasibility</li></ul><p>This prevents the strategic plan from becoming bloated or unfocused.</p><p><strong>8. Convert SWOT Analysis Into Actionable Strategies</strong><br>Formulating your analysis into actionable strategies is a crucial aspect of this process. This strategy action plan should be specific and identify who will do what and by when. Progress should be periodically reviewed and action plans updated or revised if necessary to ensure your team is focused on following through on specific assignments. This also builds accountability into your plan.</p><p>Some examples may include the following:</p><p><strong>Strength Strategy</strong><br>Strong therapy outcomes - Market to hospitals for short term rehab referrals.<br><br><strong>Weakness Strategy</strong><br>High CNA turnover - Implement retention incentives and mentorship programs.<br><br><strong>Opportunity Strategy</strong><br>Growing behavioral health needs - Develop a specialized dementia/behavioral unit.<br><br><strong>Threat Strategy</strong><br>Competitor expansion - Strengthen community outreach, employee recruitment and retention, and referral relationships.<br><br><strong>9. Integrate SWOT into QAPI and the F</strong><strong>acility Assessment</strong><br>A skilled nursing facility’s strategic plan must align with:<br></p><ul><li>QAPI performance improvement projects (PIPs)</li><li>Annual facility-wide assessment</li><li>Emergency preparedness plan</li><li>Budgeting and staffing plans</li></ul><p>This ensures the SWOT analysis becomes part of ongoing facility operational improvement, not a one time exercise, and is linked to these other programs or processes.</p><p><strong>10. Review and Update Annually</strong><br>A SWOT analysis should be revisited:<br></p><ul><li>Annually</li><li>After major regulatory changes or survey findings</li><li>After poor clinical outcomes</li><li>When launching new service lines</li><li>When employee turnover and agency use continue to increase</li></ul><p>This is not a complete list and only provides a few examples when you should be updating or revising your plan. This keeps the strategic plan responsive, current, and relevant.</p><p>Going forward, I would highly recommend that any health care administrator embrace this process and make it part of your strategic planning process. In some cases, I would take my entire management team off campus to a location where there are no distractions or interruptions. This exercise will help give you, your management team, and the facility the necessary direction needed to succeed.</p><p><em><br></em></p><p><em><img src="/Articles/PublishingImages/2026/Mark%20Trangsrud.jpg" class="ms-rtePosition-2" alt="Mark Trangsrud" style="margin:5px;" />Mark Trangsrud is a retired skilled nursing home administrator with experience in for-profit, nonprofit, and public sector settings, rural and metropolitan markets, and in various size facilities. He has practiced for over 41 years and has been licensed in 8 different states as a nursing home administrator as well as serving on the South Dakota and Colorado Health Care Association Boards. He can be reached at </em><a href="mailto:Metrangsrud57@msn.com" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><em>Metrangsrud57@msn.com</em></a><em>.</em></p><p><em></em><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#212121;">Provider<span class="Apple-converted-space"> </span><em>magazine includes information from a variety of sources, such as contributing experts. The views expressed by external contributors do not necessarily reflect the views of<span class="Apple-converted-space"> </span></em>Provider<em> magazine and AHCA/NCAL.<span class="Apple-converted-space"> </span></em></span><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#96607d;"><em><span style="text-decoration:underline;"><a href="/About/Pages/Submit-Article.aspx" title="https://www.providermagazine.com/About/Pages/Submit-Article.aspx" data-outlook-id="badae440-b0ce-4219-9c08-f7e349a8e3d6" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" style="color:#96607d;margin-top:0px;margin-bottom:0px;">Learn how to submit an article.</a></span></em></span></p><p><br></p> | 2026-09-24T04:00:00Z | <img alt="SWOT" src="/Articles/PublishingImages/2026/swot_r.jpg" style="BORDER:0px solid;" /> | Management | Mark Trangsrud | Conducting a SWOT analysis is the first step in strategic planning. This process begins to lay out your road map in setting direction for your facility. |
| The Strategic Impact of Readmission Performance: Strengthening Quality Measures, Five-Star Ratings, and Referrals | <div><strong class="ms-rteForeColor-2">ADVERTORIAL</strong></div><div><img src="/Articles/PublishingImages/2026/0926_RealTime_nurses.png" alt="nurses with a patient" class="ms-rtePosition-2" style="margin:5px;width:350px;height:350px;" /><br></div><div>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.</div><div><br></div><div>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.</div><div><br></div><div>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 <a href="https://www.nshorehc.com/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" title="North Shore Health">North Shore Health,</a> and Kathy Derleth, RN, BSN, Customer Success Manager at <a href="https://realtimemed.com/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" title="Real Time Medical Systems">Real Time Medical Systems,</a> 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.</div><h2>Readmissions Influence More Than Patient Outcomes</h2><div>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.</div><div><br></div><div>"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."</div><div><br></div><div>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."</div><div><br></div><div>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.</div><h2>Why Retrospective Reviews Fall Short</h2><div>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.</div><div><br></div><div>"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.”</div><div><br></div><div>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.</div><div><br></div><div>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.</div><h2>Operationalizing Quality Improvement</h2><div>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.</div><div><br></div><div>"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."</div><div><br></div><div>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.</div><div><br></div><div>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.</div><h2>Creating Consistency Across a Facility Network</h2><div>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.</div><div><br></div><div>"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.</div><div><br></div><div>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.”</div><div><br></div><div>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.</div><div><br></div><div>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.</div><div><br></div><div>Belongia and Derleth will expand on these strategies and lessons learned during their <a href="https://realtimemed.com/event/conference-ahca-ncal-conference-expo-delivering-solutions-26-oct26/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" title="DS 26">AHCA/NCAL Conference & Expo</a> session, <strong><em>Readmission Risk & Enhanced Quality: SNF's Strategic Role,</em></strong> this October.</div><br><div>For more information, visit <a href="https://realtimemed.com/who-we-serve/health-plans/?utm_campaign=07.2026_medcity_news&utm_source=medcity&utm_medium=website" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" title="Real Time Medical Systems" target="_blank">www.realtimemed.com.</a></div><br><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#212121;">Provider<em> magazine includes information from a variety of sources, such as contributing experts. The views expressed by external contributors do not necessarily reflect the views of Provider magazine and AHCA/NCAL.<span class="Apple-converted-space"> </span></em></span><span style="font-family:aptos, sans-serif;font-size:14.6667px;color:#96607d;"><a href="/About/Pages/Submit-Article.aspx" title="https://www.providermagazine.com/About/Pages/Submit-Article.aspx" data-outlook-id="badae440-b0ce-4219-9c08-f7e349a8e3d6" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="color:#96607d;margin-top:0px;margin-bottom:0px;"><em><span style="text-decoration:underline;">Learn how to submit an article.</span></em></a></span><br> | 2026-09-17T04:00:00Z | <img alt="nurses with a patient, in bed" src="/Articles/PublishingImages/2026/0926_RealTime_nurses.png" style="BORDER:0px solid;" /> | Readmissions;Caregiving | Belongia and Derleth | How one skilled nursing provider leveraged proactive risk management and live data analytics to reduce return-to-hospital rates and improve value-based care outcomes across its facility network. |