The Value of Bridging the Data Gap Between Acute and Post-Acute Care

This article was originally featured in Healthcare IT Today.

When acute care providers look at hospital readmissions, it is natural to think about what is being done once the patient is discharged. However, what many forget is that a large portion of patients are discharged to a post-acute facility. In order for post-acute care teams to address things like readmissions and length of stay (LOS), it is essential for acute care providers to create collaborative relationships with their post-acute partners. This includes sharing of data between organizations. Plus, this need is even more apparent when an acute care organization is engaged in value-based care contracts.

This was one of the key learnings I found in this amazing case study published in the Management in Healthcare Journal, titled “Improving patient outcomes while reducing readmissions with data analytics”. The article was written by Margie Latrella, VP, Clinical and Network Quality at Real Time Medical Systems (Real Time), and Lavana Baldasare, Manager — Clinical Transformation at St. Joseph’s Health, and shares their experience rolling out a successful post-acute skilled nursing network strategy.

Let’s take a look at just a few of the results. First, St. Joseph’s Health had a total cost of care savings of $1.6 million dollars in the first year. Readmission rates decreased from 24% to 17.8% in year one and continued to decrease in the following years. In fact, overall, St. Joseph’s Health realized a 43.3% reduction in readmissions since the inception of this effort. Additionally, LOS went from 24.8 days in 2019 to an average of 21.6 days in 2023.

Those are numbers that every healthcare organization can appreciate. Plus, I love that those figures represent a meaningful difference financially for the healthcare organization and more importantly, for patients receiving the care. So, how did they accomplish these results?

You should definitely read the full article for all the details, but one of the key elements was providing a dedicated nurse navigator at St. Joseph’s Health to access the right data to be able to support their patients in the skilled nursing facilities (SNFs) more effectively. They outline how previous efforts to look at post-acute data failed because it was too old, too outdated, and too time consuming to analyze to be useful. Here’s a list of the types of data they used and the challenges with that data being useful:

• Claims data — 3 to 9 months old.
• CMS Stars data — takes a year to change a star rating.
• Minimum Data Set (MDS) data — 30 to 90 days old.
• Post-acute care self-reported data (time consuming, hand collected, and not based on reportable data).

To solve this problem, St. Joseph’s Health utilized a post-acute EHR agnostic analytics platform from Real Time to view live data for patients who were discharged to their SNF network providers. This data was reviewed by their post-acute nurse navigator to better monitor discharged patients and proactively address those at highest risk for a readmission. One of the key components was a daily report that risk stratified patients, using 400 clinical indicators to help the nurse navigator prioritize their efforts. A report like this would not be possible if it were not for the real-time data they receive from the SNF.

It turns out that this proactive effort by St. Joseph’s Health, supported by high quality data, helped create deeper relationships with their SNF partners. The data analytics being utilized drove better collaboration amongst care teams, providing key areas where acute and post-acute providers could do a better job working together for the betterment of the patient. Furthermore, the data helped St. Joseph’s Health prioritize who was in their network based on the quality of the care their patients received.

Lest you think the benefit was all for the acute care provider. The article outlines a number of great benefits to the SNF as well:

• Improved performance and collaboration will lead to increased referrals from the health system, ACO, or payer = HIGHER VOLUME!
• Appropriately discharging patients and receiving new complex post-acute patients, their patient-driven payment model reimbursement rate may be higher compared with those ready for discharge. Improved 5-Star ratings.
• Improved patient satisfaction, which can increase referrals from past patients.
• Improved quality of life for the patient, less time away from home.
• Improved patient clinical outcomes.
• Potential shared savings opportunity, lower post-acute spend increase shared savings.

Needless to say, it was powerful to see how much both acute and post-acute care providers benefited from the sharing of data, as well as their proactive efforts to reduce readmissions and LOS. Plus, as I mentioned earlier, the patients are the ones who win the most. Check out all the details in the article, “Improving patient outcomes while reducing readmissions with data analytics,” to learn more about how St. Joseph’s Health and Real Time partnered to achieve such great results.

You may view this article on the Healthcare IT Today website, here.