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What if the most crucial moments for health plan quality doesn’t happen in a boardroom, but across the entire post-acute journey — from the hospital bed to SNF, through the SNF or long-term care (LTC) stay, and finally back home? For Medicaid and Dual Special Needs Plans (DSNPs), the focus is moving away from retrospective reports and toward what happens in real time — especially during and between these transitions. Increasingly, these handoffs and post-acute stays are where performance is truly tested, where quality scores can rise or fall, and where the future of plan ratings and reimbursement is decided.

From Compliance to Consequence

The tightening of measure cut points and reporting specifications means plans can no longer depend on quarterly claims data arriving well after the fact. The new reality? Only operations — what happens in real time, when members leave SNFs or long-term care (LTC) beds — can reliably move the needle on the metrics that matter.

The DSNP Pressure Cooker

Nobody feels this pressure like DSNPs. Why? These plans cover members with the densest clusters of clinical and social complexity: multiple comorbidities, behavioral needs, disjointed provider networks, and most critically, one of the highest rates of post-acute utilization. The risk is real. If transitions break down during admission to SNF, discharge planning, medication reconciliation, or service coordination — or if issues during the stay go unnoticed—those gaps in care become readmissions, flagged events, and costly reductions in quality ratings in the next rating cycle. 

The Insight Gap That Hurts

Despite advances in EHRs and interoperability, most health plans remain blind to post-acute events until it’s far too late. Claims typically land weeks after discharge—long past the window for outreach, documentation, or member engagement. By then, opportunities to avoid a costly readmission or complete an essential Transitions of Care (TRC) element have vanished. The same is true for in-stay complications: infections, therapy setbacks, or medication changes that, if flagged early, could prevent a hospital return.

What Real-Time Support Really Looks Like

Supporting transitions isn’t about heroic care coordination. It’s about equipping teams with the right insights — live SNF/LTC census, estimated discharge dates, therapy and clinical notes, current medications, and risk signals — so they can anticipate needs before and during the stay. For transitions back home, that means connecting the dots: DME, home health, primary/specialist follow-up, transportation, and caregiver education. And it means acting on in-stay alerts—like a sudden functional decline or missed therapy milestones—before they escalate into readmissions. 

Readmission Prevention Starts Before Discharge

Reducing 30-day hospital returns isn’t just another box to check; it’s quickly become the main strategy for improving quality in public programs. Every readmission avoided improves not only the Plan All-Cause Readmissions measure but also strengthens interconnected metrics such as medication safety and timely follow-up. The key: intervene early and often during the SNF or LTC stay, not just after discharge. 

Prioritize on the Members Most At Risk

Simply put, not every member flagged for outreach is equally at risk. By using smart insights — like who’s most likely to land back in the hospital or who’s showing warning signs during their SNF stay — plans can put their energy where it’s needed most. Instead of trying to reach everyone, teams use focused lists and make sure every bit of effort delivers real results.

Work Smarter for Scores That Matter

Quality measures shape everything from ratings to revenue, so plans have to line up their efforts with what matters:

• Transitions of Care (TRC): Real-time insights on admissions, in-stay changes, and discharges means the right people know what’s happening, at the right time, so nothing important falls through the cracks.
• Plan All-Cause Readmissions (PCR): Targeted interventions during the SNF stay—such as addressing infection risk or therapy delays—are as critical as post-discharge follow-up for reducing avoidable hospital stays. 
• Medication Reconciliation Post-Discharge (MRP): Making sure every member gets their medication list reviewed after leaving the hospital helps prevent dangerous errors and keeps quality measures strong.
• Follow-Up After Emergency Department Visit (FMC): Prompt follow-up after ED visits, especially for members with multiple chronic conditions, is another crucial measure for driving better outcomes and ratings.
• Related HEDIS/Stars Metrics: Improvements cascade— getting one touchpoint right often lifts several scores at once, so improvements start to multiply.

Outcomes Backed by Evidence

Health plans that stay up to date on member transitions into, during, and out of SNFs or hospitals consistently show meaningful reductions in readmissions, shorter SNF lengths of stay, and better continuity of care. It’s not more activity, but smarter, well-timed intervention at the right points of care based on actionable insights.

Building for Scale

Consistent performance requires more than a reliance on standout providers. To support transitions and in-stay monitoring across geographies at scale, plans must knit together thousands of hospitals and long-term care providers, ensuring processes are repeatable and reliable. More connections mean fewer blind spots and more reliable execution, every time a member changes care settings.

An Operations Blueprint

Leading Medicaid and DSNP plans are staying ahead of the competition by:

• Establishing real-time notification systems for SNF/LTC admissions, in-stay status changes, and discharges, integrated with TRC workflows.
• Embedding clinical insights—including diagnoses, medications, therapy progress, and estimated discharge dates—into care management protocols.
• Prioritizing members based on readmission risk and aligning outreach to specific needs during the stay and after discharge.
• Closing the feedback loop with facilities around recurring issues such as infections, complex medication regimens, or equipment delays.

The Business End of Quality Measurement

Sustained quality improvement depends on consistent processes rather than individual effort. Top-performing teams monitor leading indicators like timely admission and discharge insights, in-stay alerts, medication reconciliation completion, and outreach to high-risk members, reviewing these collaboratively with provider partners to drive continuous performance gains.

The post-acute journey is no longer a peripheral concern. It is now the core of quality operations in Medicaid and DSNP plans. Organizations that recognize this, implement effective processes, and scale best practices will outperform their peers. Those who delay action risk significant financial losses in future rating cycles — and will find themselves learning expensive lessons at the business end of quality measurement.