​What do accountable care organizations (ACOs), hospitals, and health systems participating in value-based payment models (such as the Bundled Payment Care Improvement Advanced) look for when referring patients to a post-acute care (PAC) facility? They want a reliable partner who not only shares their goals of well-coordinated care, improved patient outcomes, and reduced costs but also delivers with proven results. 

It’s no secret that post-acute providers, especially skilled nursing facilities (SNFs), are facing more challenges than ever before. The steady decline in occupancy and critical staffing shortages were exacerbated by the pandemic. According to the NIC MAP Data Service, SNF census hit an all-time low last December, and while the numbers are stabilizing, occupancy is down 13 percent from pre-COVID levels.

Recruiting and retaining quality physicians, nurses, and certified nurse assistants post-COVID will only get tougher with nursing homes in almost every state reporting significant staffing limitations. These issues, compounded with the actual cost of fighting the pandemic, further escalate rising operational expenses.

Yet, as value-based care models (VBC) continue to evolve, ACOs, hospitals, and other payers expect their post-acute network partners to improve the quality of care and deliver better clinical and financial outcomes. This puts SNFs under even more scrutiny in their efforts to gain referrals, operate efficiently, and retain staff.

To remain an essential provider in the market and earn steady hospital referrals, SNFs must adopt a value-based care mindset across the entire organization. Technology is one of the keys to this VBC transformation—in the form of data analytics. By using meaningful data to better manage patient care, SNFs can become a stronger partner for their residents, referral sources, payers, and the communities they serve.

Moving the needle on key performance metrics using live data

In order to perform well under bundled and other VBC payment models, ACOs and hospitals are inherently tied to their post-acute facilities’ ability to improve patient outcomes—namely readmission rates and length of stay. That’s why these entities are turning to their high-performing network partners to improve the patient experience and maximize potential savings.

And because acute care providers are responsible for managing patients during the post-acute stay, they are targeting the costliest line item—skilled nursing facilities—to reduce costs. As reported in the MedPAC July 2020 Data Book, skilled nursing alone accounts for almost half of Medicare fee for service post-acute hospital expenditures, thus representing a prime target for payers to reduce total health care dollars.  

There’s a real opportunity for SNFs too.

Many SNFs have a massive amount of patient and facility data readily available in their electronic health record (EHR) that—when gathered and analyzed in real-time—can reveal meaningful information and help move the needle on key performance measures. They just need the right software to use it to their advantage.

By using data analytics to leverage EHR data, post-acute facilities gain valuable insights that empower care teams to make more informed clinical decisions. Equipped with actionable patient and facility-level data, SNFs can improve coordination efforts among transitioning providers and shorten patient stays.

For example, care teams can proactively identify and stratify residents at high risk for readmissions, particularly during the first 72 hours of transition to the SNF when they are most vulnerable. With timely, evidence-based, and actionable alerts, the care team can treat them in the facility before the patient’s status worsens.

And with the right data, SNFs can establish clinical pathways to reduce variability in the way conditions are treated. By using interventional analytics to understand how the patient is doing in the moment compared to an established clinical baseline of when they arrived, clinicians can intervene in a more timely fashion to mitigate the risk of decline and need for hospitalization. With a better clinical line of sight based on live data, SNFs can also reduce length of stay by making even more informed decisions on when the resident would be safe to transition back to the community.

Proving value as an ideal PAC partner

Aging adults entering nursing homes and assisted living are sicker and frailer than ever before, which makes the PAC facilities that care for them an increasingly vital component of the health care continuum.

Simply relying on claims or the Minimum Data Set (MDS) to inform patient care is no longer an option; instead, staff need immediate access to actionable information at the point of care. The typical SNF EHR is so fragmented, finding the “must have” clinical information is like searching for a needle in a haystack.

Clinicians need live, continuous data analysis that helps keep the entire team well-informed on the highest risk patients based on their status today and not based on their most recent claims or their latest MDS, often weeks to months old. With actionable data that helps care teams assess and prioritize patient needs in real time, staff can target specific at-risk residents on rounds while offering a brief greeting to others.

To see the big picture—and prove their value as a preferred network provider—SNFs also need dashboards and reports based on information as recent as the day the data is entered into the EHR instead of pulling data from the MDS that may be three months old.

And SNFs need to share that data with their health care partners. Data transparency and interoperability allows all providers invested in patient care to monitor clinical status along the care continuum and drive collaboration when needed.  

With interventional analytics software that assesses live patient EHR data 24/7/365, SNFs can better coordinate with their referral partners to effectively transition patients between care settings, shorten length of stay, and keep residents out of the hospital, ensuring patients return to their homes safely.

Do you have the right technology in place to effectively coordinate care, improve patient outcomes, and reduce costs so that you can get the referrals you measurably deserve?

As chief medical officer, Steven Stein, MD, draws upon his vast knowledge of both the post-acute and payer markets to guide the clinical advancements of Real Time Medical Systems’ Interventional Analytics platform for post-acute providers, health systems, accountable care organizations, physician groups, and managed care organizations. Stein served on the White House Council on Aging for both the Clinton and Obama administrations. Stein is board-certified in internal medicine and geriatrics.