How provider collaborations are cutting hospital readmissions
This article was originally featured in Modern Healthcare.
Health systems, accountable care organizations and others are bringing extra staff and tracking technology into post-acute care to reduce hospital readmissions.
Health systems, such as OSF Healthcare, and accountable care organizations, such as Provider Partners Connect Care are using remote patient monitoring equipment, electronic medical records software and additional staff to ensure patients don’t have a set-back that will send them back to the hospital. Readmissions add costs that ripple through the healthcare system and the Centers for Medicare and Medicaid Services penalizes hospitals and nursing homes for higher-than-predicted readmissions within 30 days of a hospital discharge.
Related: Hospitals seek new way to deliver nursing care
About 23% of patients discharged from acute care hospitals to skilled nursing facilities bounced back to the hospital within 30 days based on CMS data between 2019 and 2023. Hospitals with higher-than-predicted readmissions face Medicare reimbursement penalties of up to 3% under the Hospital Readmissions Reduction Program and nursing homes face penalties of up to 2% under the Skilled Nursing Value-based Purchasing program.
Some health systems have made progress reducing unnecessary readmissions and the associated penalties. This year, 7% of hospitals are being charged penalties of 1% or more compared with 7.5% in 2024 under the Hospital Readmission Reduction Program.
Here’s how some providers have collaborated with health care companies to cut down on readmissions.
OSF Healthcare and Puzzle Healthcare
Peoria, Illinois-based OSF Healthcare is among the health systems doing a better job preventing patients from bouncing back to the hospital after they are sent to skilled nursing care. A collaboration with Puzzle Healthcare helped OSF reduce readmissions to 9% in 2024 from 29% in 2022, said Mathhew Nieukirk, OSF Healthcare’s director of skilled nursing facility practice. Medicare penalties dropped to 1.4% from 2.7% over that same time.
Puzzle Healthcare, headquartered in Chicago, deploys rehabilitation clinicians, or physiatrists, to skilled nursing facilities to provide specialized care to at-risk patients. Puzzle Healthcare also uses virtual care managers and remote patient monitoring to track patients for up to 90 days after a hospital discharge.
“The goal is to make sure the patient is getting to that optimum level, back to baseline or where they are successful and able to go home,” Nieukirk said.
Puzzle Healthcare deploys physiatrists to visit OSF patients in about 80 Illinois nursing homes two to five days a week. The clinicians help coordinate pain management and therapy with nursing home staff, Nieukirk said. They also help identify symptom exacerbations that could send patients back to the hospital.
Nieukirk said OSF initially had trouble selling some nursing home administrators on the idea of bringing in outside clinicians and technology to track patients.
Randi Lienhart, who oversees The Loft in East Peoria, Illinois, said she initially didn’t think the nursing home needed additional support. She said she changed her mind because she found it valuable having the physiatrist provide an extra set of eyes on patients when physicians weren’t onsite.
“She makes sure OSF patients are meeting their goals,” Lienhart said. “We aren’t sending patients back to the hospital, we can manage them in-house and make sure they do go home.”
Puzzle Healthcare has similar arrangements with 11 other health systems and about 275 skilled nursing facilities across 12 states, said Puzzle Healthcare CEO Dr. Ahzam Afzal. He said the company bills Medicare directly, so providers don’t pay anything out-of-pocket for services.
Select Medical
Other post-acute providers are also keeping patients from coming back to the hospital by consulting with outside physicians through telehealth, as well as offering staff more training.
Select Medical is training staff to better identify when a patient’s condition is deteriorating as it cares for more high-acuity patients, said Executive Vice President and Chief Medical Officer Dr. Samuel Hammerman. He said the company’s recovery and rehabilitation hospitals also collaborate more closely with health system partners by bringing in their physicians for virtual visits when necessary.
The Mechanicsburg, Pennsylvania-based company offers specialized post-acute care and operates about 140 critical illness recovery hospitals and rehabilitation hospitals across 39 states. It has partnerships with health systems, such as the Cleveland Clinic and SSM Health.
Hammerman could not say how many readmissions the strategy has prevented or how much money it has saved Select Medical and its partners. But he said better training and communication between providers is the best defense against readmissions.
“If you pay attention to the little things and create a process around it then you are apt to not make any errors of omission,” Hammerman said. “That tends to be the winner-take-all recipe.”
Provider Partners Connect Care ACO and Real Time Medical System
Some healthcare organizations are finding technology alone can also be an effective tool to keep patients out of the hospital.
Provider Partners Connect Care, a Maryland-based ACO, partnered two years ago with healthcare technology company Real Time Medical System. The company embeds an analytics tool in nursing homes’ electronic health records, with their permission, to flag patients at risk for a hospital admission, said the ACO’s CEO, Keith Persinger.
The technology scans patient records for signs a patient’s condition is at risk of deteriorating and alerts nursing home staff so they can intervene, said Real Time Medical Systems’ Founder and Executive Chair Dr. Scott Rifkin.
“If you are a director of nursing, you know your team doesn’t have the time to be searching for all of that stuff every day. It’s easy to notice that someone is short of breath, but it’s harder to know if there is something that is not symptomatic yet,” Rifkin said.
Provider Partners Connect Care has been using Real Time Medical Systems’ technology to help track about 6,000 nursing home patients enrolled in CMS’ ACO Realizing Equity Access and Community Health, or ACO REACH model, Persinger said. He estimates the technology has helped reduce unnecessary hospitalizations by about 25% over the last two years. While he wouldn’t put an amount on the cost savings, he said it could be significant.
“The cost of [an intervention] could literally be less than $10 with no disruption of patient care. The cost of an [emergency department] visit that converts to an admission is approximately $20,000. That is the big difference,” Persinger said.