Health System Leverages Post-Acute Data Transparency to Drive Clinical Performance and Reduce Cost

In a value-based care world, payers and providers are accountable for the entire patient journey; therefore, their long-term success and financial viability are inherently tied to the performance of their post-acute care (PAC) network of providers. Approximately 50% of PAC costs for ACOs and CMS’s Bundled Payments for Care Improvement programs come from skilled nursing facilities (SNFs). Now is the time to align value-based care initiatives to deliver better clinical and financial outcomes across the entire patient continuum.

As post-acute care (PAC) spend continues to rise it is essential for ACOs, hospital providers, health plans, and payers to take proactive measures in finding innovative and cost-effective data-driven solutions/strategies to meet the future demands of healthcare. Yet, disparate EHR systems between acute and post-acute providers continue to pose challenges in the ability to access live patient data across care settings. Hospitals often lose sight of patients when they transition to PAC mostly due to misinformation, miscommunication, and delays caused by a lack of interoperability. Utilization of an EHR-agnostic platform, which mitigates interoperability, can foster seamless implementation of standardized care pathways, improve care transitions, better manage patient outcomes, and ultimately reduce total costs within post-acute networks by reducing readmissions and length of stay. This level of interoperability gives stakeholders in the entire patient journey a new game plan to manage and strengthen their PAC networks that claims data and ADT feeds do not supply.

In 2019, St. Joseph’s Health System (SJHS) implemented such a platform and instituted a PAC nurse navigator (NN) role to manage their value-based patients in the PAC setting. As a result, their MSSP ACO, Mission Health Coordinated Care (MHCC), realized a significant reduction in readmissions from 24% to 20% and achieved a total cost of care savings of $1.779M its first year. Due to their successful post-acute strategy and programming, the project was scaled to include all patients in value-based contracts. During this session we will explore how SJHS utilized a cloud-based interventional analytics platform to gain direct line of sight into SNF patient EHRs, drawing attention to high-risk patients, along with a PAC Nurse Navigator to review the data on a daily basis and communicate changes in patients’ clinical status with SNF staff – to proactively prevent avoidable readmissions and manage length of stay challenges. We will show how the data also allowed for the creation of clinical pathways for chronic conditions that the PAC facilities often encounter. Insights and experiences, best practices, and lessons learned will be shared on how management of patients in PAC has provided SJHS with multiple opportunities to impact quality, total cost of care, and improve patient outcomes and satisfaction.

LEARNING OBJECTIVES

• Describe how post-acute data transparency empowers clinical teams to immediately identify trends and improve network performance and patient outcomes in PAC facilities
• Implement strategies utilizing live post-acute data to reduce readmissions and minimize length of stay resulting in improved quality performance and total cost of care savings in post-acute populations
• Analyze performance of post-acute providers to implement data-driven standardized care pathways for common chronic conditions in aging/post-acute care populations

SPEAKERS

• Lori Calderone, Director, IPA of North Jersey/Mission Health Coordinated Care ACO, St. Joseph’s Health Partners CIN
• Phyllis Wojtusik, RN, Executive Vice President, Value-Based Care, Real Time Medical Systems

This session is presented as part of the 2023 Fall Managed Care Forum.