Managing the Post-Acute Network: Care Coordinators + Live Data Analytics = Value-Based Care Success

In value-based care (VBC), ACOs, Hospitals, and Health Systems are accountable for the entire patient journey. With Medicare spend reaching more than $28.5 billion¹ for Skilled Nursing Facilities alone in 2022, providers are incentivized to produce higher quality, coordinated care that improves patient health outcomes and reduces spending – making long-term success and financial viability inherently tied to the performance of post-acute care (PAC) partners. As the landscape continues to transform, many providers are building preferred post-acute networks (PAN). However, there is still a lot of work to be done in creating successful care coordination efforts that align with VBC initiatives, including incorporating effective care transitions, clinical pathways, standards of care, risk stratification, appropriate length of stays, and reducing hospital readmissions. Consisting of multiple facilities in many different geographical locations that serve the diverse senior population spanning our nation, effectively managing these large post-acute networks to be successful in VBC has proven to be a formidable challenge.

To foster seamless implementation of clinical pathways, improve care transitions, better manage patient outcomes, and reduce total costs within the post-acute network, Vytalize Health, a major ACO aggregator covering more than 250,000 Medicare beneficiaries across 36 states, instituted a program that powers dedicated care coordinators with live data analytics. Early data from the first year of program execution point to a notable 30% reduction in readmission rates for Vytalize patients receiving care from SNFs participating in the initiative.

This session delves into the strategies and tools used by Vytalize Health to manage their PAN. With invaluable information for all risk-bearing providers, Jenny Doyle, Director of Network Product for Vytalize Health, will discuss how they manage their PAN through a partnership that brings dedicated care coordination and post-acute data analytics into the mix. Jenny will be joined by Phyllis Wojtusik, RN, EVP of Value-Based Care of Real Time Medical Systems, who will dive deeper into the “why” and “how” care coordinators should be leveraging post-acute data to deliver effective care transitions, establish clinical pathways, monitor high-risk patients, lower length of stays, reduce readmissions, and increase network referrals. The session will also share best practices and lessons learned regarding the role live data plays in improving quality of care, prioritizing patients in clinical need, alerting to clinical interventions, and enhancing overall care delivery at the network, facility, and patient levels. By doubling down on care coordination efforts through post-acute data transparency, this session will showcase how providers can drive value-based care initiatives with their PAN partners.

¹ March 2023 MedPAC

Learning Objectives

• Enhance care coordination efforts through the use of live post-acute data analytics to improve patient outcomes and reduce costs
• Implement tools and strategies to effectively manage a post-acute network, regardless of size
• Drive value-based care initiatives across the post-acute network by leveraging live data to establish clinical pathways, risk stratify and prioritize patients, enhance collaborative care, and reduce rehospitalizations

Speakers

• Jenny Doyle, Director, Network Product, Real Time Medical Systems
• Phyllis Wojtusik, RN, EVP, Value-Based Care, Real Time Medical Systems

This presentation is presented as part of the 2024 Fall Managed Care Forum.