Readmission Risk & Enhanced Quality: SNF’s Strategic Role

According to a 2022 JAMA Network study, 1 in 5 Medicare beneficiaries discharged from the hospital receive post-acute care in a skilled nursing facility (SNF), costing over $28 billion annually. Nearly one-quarter are readmitted to the hospital within 30 days – a key metric targeted by the Centers for Medicare & Medicaid Services (CMS) through its SNF Value-Based Purchasing (VBP) program, which ties financial incentives or penalties to readmission rates. The CMS Five-Star Rating System, which publicly benchmarks SNF performance across staffing, health inspections, and quality measures, is closely linked to these outcomes. A 2020 study (Annals of Long-Term Care) found that patients in higher-rated SNFs had a 13% lower risk of 30-day rehospitalization, underscoring how quality ratings not only reflect clinical performance but also influence referrals from hospitals, ACOs, and Value-Based Care plans.

This presentation will address the critical need for post-acute providers to maintain low baseline rehospitalization rates and demonstrate consistent improvement through the use of AI-driven data analytics. We will explore the impact hospital readmissions have on patient care, reimbursement, and SNF quality ratings while highlighting actionable strategies SNFs can implement to reduce readmissions and improve their Five-Star ratings. A key focus will be on how to leverage live data analytics to support these efforts without adding administrative burden to already overworked care teams. To illustrate these strategies, Tina Belongia, Chief Clinical Officer of North Shore Health, will share how she and her team implemented a proactive, data-driven approach to risk stratify patients, prioritize clinical interventions, and manage quality measures daily across their 59 facilities, resulting in measurable improvements in value-based care outcomes and performance.

This session will promote a deeper understanding of how quality measures and live data can be operationalized to drive better care outcomes, enhance regulatory performance, and position SNFs as preferred referral partners.

Learning Objectives

• Analyze the relationship between hospital readmission rates, CMS’s SNF Value-Based Purchasing (VBP) program, and the Five-Star Rating System to understand their impact on reimbursement and referral patterns
• Apply AI-driven live data analytics to identify high-risk patients, prioritize clinical interventions, and manage quality measures in daily SNF operations without increasing administrative burden
• Evaluate the effectiveness of proactive data strategies in reducing 30-day rehospitalizations and improving Five-Star ratings, using real-world outcomes from North Shore Health’s implementation across 59 facilities

Speakers

• Tina Belongia, RN, BSN, Chief Clinical Officer, North Shore Health
• Kathy Derleth, RN, BSN, Customer Success Manager, Real Time Medical Systems

This session is part of the educational agenda at the AHCA/NCAL Convention & Expo Delivering Solutions ’26.