Executive Series: The Integral Role Technology Plays in Value-based Care – Paving the Way to Improve Efficiencies, Care, and Costs for Skilled Nursing Facilities Within Value Based Care Programs

July 20, 2022 | Written by: Dr. Steven Stein, Chief Medical Officer

Every day until 2030, 10,000 Baby Boomers will reach the age of 65 and seven out of ten people will require long-term care. With over 1.3 million patients residing in over 15,600 nursing homes domestically, post-acute providers bear the responsibility of ensuring the quality of care being provided, while simultaneously trying to achieve revenue goals and increase occupancy.

With the integration of value-based care (VBC), fee-for-service models have become outmoded and are now evaluated on the quality of care provided, improved health outcomes, and patient satisfaction. Ultimately, driving a drastic shift in current care delivery models and higher demand for post-acute services with providers being rewarded for both efficiency and effectiveness. This demand for post-acute services creates a favorable environment to deliver VBC directly to patients within skilled nursing facilities (SNFs), as opposed to having the patients readmitted to the hospital. With VBC on the forefront of everyone’s minds within healthcare, SNFs can leverage their PAC services to the appropriate population and implement quality of care in a streamlined environment.


Improving Quality of Care While Driving Down Costs with Value-Based Care 

By taking a more proactive role in working with healthcare partners including payers, hospitals, ACOs, and aligning VBC initiatives, post-acute care (PAC)/ SNFs can increase their referrals and improve occupancy/census by partaking in VBC. In aligning care goals with partners, PAC providers can reduce financially regulatory penalties (i.e., rehospitalization penalties) and improve star ratings while improving the quality of care and reducing unnecessary costs.

Furthermore, with less and less patients leaving hospitals and going to SNFs, it’s never been a more competitive time for referrals. With the altered way nursing homes are being measured, now, based on the value they offer both the patient and the payer/provider at financial risk. This conclusively drives for higher quality of care leading to better patient outcomes and collaboration across providers. A successful SNF facility will be required to continue to offer more and more value for the cost they incurred.


Hinderances Observed by Skilled Nursing Facilities in the On-going Mission to Embrace Value-Based Care 

SNFs are often faced with a host of challenges daily that can alter the delivery of VBC. Being able to capture the appropriate patient documentation is crucial for VBC outcomes. With the imploding staffing challenges, it has made it increasingly more difficult to maintain consistent documentation processes. With PAC providers adding patient documentation in various places within the EHR (physicians, nurses, agency staff, etc.), being able to capture the needed documentation from different areas to create a true clinical picture and know when a patient is declining and needs care intervention has become increasingly more difficult to identify. PAC facilities have the ability to treat the patient in place, quicker and in a more responsive manner, which can also help minimize length of stay (LOS) and making sure their achieving VBC outcomes. It’s important to leverage any documentation available and make sure patients are going home safely and patients who shouldn’t be going home, don’t, while simultaneously ensuring you have the care available when they need it to be there.

Another significant challenge faced by SNFs is reducing readmissions within PAC. Because documentation isn’t consistent, it is hard to prioritize care – knowing which patients to see first on shift changes. Providers want to send patients to places that don’t have readmissions, the number of people now going to nursing homes is a lot less. By implementing the right documentation, PACs can help to alleviate the staffing challenges their facing while prioritizing the quality of patient care and quality outcomes.

A third challenge SNFs often face is properly managing LOS. Providers pay a significant cost when sending a patient to a SNF or PAC setting dependent on the amount of time a patient needs in these settings. While PACs are looking to attain more LOS to increase their revenues, VBC commands lower LOS in alignment with patient quality of care. Having the right documentation, both by diagnosis and functional status, provided daily, will help justify increased LOS suggesting that a patient is not ready to go back home. However, having the documentation needed to improve and intervene in care can also help reduce the LOS when necessary.


Providing Efficiencies to Improve Census, Care, and Costs 

The increased use of technology has helped providers utilize reliable data to make informed business decisions. While this structure is inherently appealing for all parties involved, the advancement of technology has fueled its widespread acceptance. With staffing shortages and high turnover of staff, efficiency is even more important and communication across disciplines and settings has never been more imperative. To deliver successful VBC, one is required to have those characteristics and technology allows for filling those gaps in staff and inconsistencies of care.

By integrating technology into your workflow, you can gain access to a clinical line-of-sight that allows focus on care delivery and member experience while creating a successful VBC platform. Technology also identifies diagnosis that have yet to be documented. As we think about disease, disease interactions, the more comprehensive we can be in knowing the patients’ diseases, the greater the chance were going to delivery well-informed clinically sound care that will reduce rehospitalizations. Technology also helps to identify patterns and trends that might otherwise be missed or things that tend to go by the waste side when staffing is short.

With the continued growth and push for VBC models, PACs can invest in technology solutions to achieve VBC goals. Real Time Medical Systems (Real Time), can help reduce administrative burdens and be more efficient with less staff. Real Time is helping to achieve VBC goals by delivering clinical line of sight into the patient’s PAC journey through the Interventional Analytics, ensuring the right care at the right time. While also monitoring length of stay and reducing avoidable readmission rates by intervening in care before adverse events arise, resulting in significant total cost of care savings.

To learn more about Real Time’s Interventional Analytics, contact us today.



With an extraordinary career entrenched in care management, Dr. Steven Stein’s vast knowledge of both the post-acute and payor markets guide the clinical advancements of Real Time Medical System’s Interventional Analytics platform for post-acute providers, health systems, ACOs, physician groups, and managed care organizations. As Chief Medical Officer, Dr. Stein draws upon his innovative successes to continually shape and refine solution offerings to advance care management across the continuum. 

Prior to joining Real Time, Dr. Stein held Chief Medical Officer positions at both Trinity Health Continuing Care and UnitedHealthcare, leveraging his expertise in population health, strategic planning, managed care, and high-risk patient program development to improve care outcomes. Dr. Stein also proudly served on the White House Council on Aging for both the Clinton and Obama administrations.

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