The Power of Real-Time Data in Reducing SNF Readmissions and Monitoring LOS

Reducing patient readmissions and optimizing length of stay (LOS) is critical for health plans to support and enable quality care at a lower cost. However, one significant challenge stands in the way of achieving this goal: data. Access to real-time, clinically in-depth data is lacking, especially during transitions from acute to post-acute care (PAC), such as skilled nursing facilities (SNFs) or long-term care (LTC) settings. This data visibility issue impacts the ability of care managers to intervene in time-sensitive moments.

In this blog, we’ll examine the impact of readmissions and extended LOS on patient outcomes and healthcare costs. We’ll also discuss how the real-time broad nature of patient data from North America’s largest post-acute network can empower care managers to proactively improve care quality while lowering these crucial metrics. 

Impact of Hospital Readmissions and LOS on Outcomes

High readmissions and extended LOS have a reverberating influence on the healthcare system, affecting patient health, healthcare quality ratings, the financial sustainability of health plans, and the national healthcare expenditure.

The Impact of Readmissions

• 15% Average Readmission Rate¹
• 25% Likelihood of Readmission Within 30 Days for SNF Patients²
• 67% of LTC Readmissions Are Avoidable³
• Average Cost of Readmission: $15,200 per patient⁴
• Readmission Penalties Will Impact 78% of Hospitals in 2024⁵

A 2023 Centers for Medicare & Medicaid Services (CMS) policy introduces a Medicare copayment for SNF visits beginning on day 21.⁶ The policy has led to shorter stays but higher readmission rates,⁶ risking adverse patient outcomes and inflating Medicare costs. Moreover, the Value-Based Payment (VBP) for Medicare Advantage patients further complicates the landscape as it incentivizes SNFs based on their risk-adjusted 30-day readmission rates. Unfortunately, this has led to more significant penalties than rewards, disproportionately impacting facilities that care for patients with higher-acuity needs or limited financial resources. The proposed FY24 focus on preventable readmissions, rather than all-cause readmissions, aims to shift the emphasis toward more sustainable patient outcomes and cost management.

The Role Care Managers Play in Reducing Readmissions and Monitoring LOS

CMS indicates that 30-day readmissions serve as an indicator of healthcare quality,⁷ highlighting that these readmissions can often be prevented through effective interventions and care transition strategies:

“Evidence has shown that providing multifaceted intervention bundles, which include components such as pre-discharge patient education, implementation of a discharge checklist, medication reconciliation, and post-discharge follow-up, are necessary to decrease readmission rates.”

Care managers play an integral role in minimizing readmissions and managing LOS by effectively coordinating care for patients during transitions from acute to post-acute settings. They monitor patient status and critical care signals to ensure care plan progress and identify high-risk patients. Collaborating with providers, they develop detailed discharge plans and address barriers that could hinder timely discharge or lead to rehospitalization. By intervening in time-sensitive moments, care managers ensure continuous high-quality care that enhances patient outcomes while reducing healthcare costs.

They maintain open communication among medical teams and offer valuable insights into the quality and performance of PAC facilities. This guidance helps patients navigate their options within their network and avoid unexpected out-of-network expenses.

Barriers To Reducing Readmissions and Optimizing LOS

The rising national healthcare expenditure, coupled with incentives to reduce readmissions and LOS makes effective care management for post-acute patients a high priority. However, achieving these seamless transitions is not without its challenges. The growing elderly population complicates the management of care transitions, as older patients often have more acute needs, leading to increased risks, costs, and a demand for timely interventions.

Barriers such as disjointed communication, limited resources, and time constraints hinder the delivery of continuous, coordinated care. Care managers often encounter clinically limited, fragmented, and delayed patient data, which complicates their ability to monitor patient status, identify high-risk patients, recognize critical care signals, and make informed decisions — particularly once patients are admitted to SNFs.

While technology tools assist and expedite care transitions and enhance communications, gaps in visibility across transitions make it difficult to obtain a comprehensive view of the patient. Additionally, manual processes, such as contacting post-acute facilities for patient updates, further complicate access to complete and current insights. Empowering care managers with better access to patient and performance data can yield significant benefits for patients, providers, and healthcare plans.

The Necessity for Real-Time Clinical Data and Advanced Analytics

Addressing data visibility challenges with real-time clinically comprehensive patient information from SNFs and leveraging advanced analytics empowers collaborative care. By ensuring resources are used efficiently, we can mitigate duplicative tests and avoidable procedures, reducing the cost of care while maximizing healthcare service utilization. This approach optimizes LOS and preventable hospitalization while enhancing effective care coordination.

With access to real-time data, care managers can effectively monitor patient status and anticipate potential complications. A full picture of each patient facilitates seamless collaboration with acute and PAC facilities during transitions, enabling timely identification of individuals at risk for readmission. They can proactively manage discharge statuses, alert teams to emerging issues, and ensure adherence to discharge goals, all of which contribute to improved patient outcomes and lower healthcare costs.

Improving Post-Acute Outcomes Through a Connected Network

PointClickCare’s PAC Management solution, built on North America’s largest connected healthcare network, tackles data visibility issues by equipping health plans with the essential tools their care managers require. PAC Management for Health Plans enables care coordination and intervention, providing insights into admissions and discharges, and advanced analytics to identify critical care signals.

Real-time Data Sharing: Care management teams gain visibility into patient locations, progress, and discharge readiness. Immediate updates on admissions and clinical milestones ensure timely admissions and effective collaboration. Access to timely data on SNF admissions and clinical assessments simplifies PAC transitions and enhances outcomes.

Clinical Data and Risk Alerts: Care managers can monitor patient status and risks with instant access to clinical data, derived from North America’s largest senior care dataset. Risk insights help ensure timely interventions and prevent avoidable rehospitalizations, while proactive monitoring of LOS supports effective post-discharge follow-ups with precise discharge information.

Customer Success

TriHealth: Decreasing Readmissions for Medicare Patients

• Reducing readmissions from 25% to 8%

“Partnership and collaboration, I think that’s really what PAC Management has done to help us support taking care of the patient.”

Lori Baker, Director of Population Health Care Management, Senior Services, and Post-Acute Network, TriHealth

Sentara Healthcare: Meeting Readmission Goals with PAC Management

• Decreasing readmissions by 14% in-network and 15% out-of-network
• Decreasing in-network costs from $11,800 in January to $8,900 in March since implementing PAC Management

“The predictive return to hospital (pRTH) risk score from PointClickCare helps us understand who’s a priority for the day, who’s a priority for the week, and flag them. We’re able to notify our SNFs which patients admitting to them are at high risk for readmission.”

Stephanie Hidalgo, Director of Care Management, Sentara Healthcare