How Payers are Better Managing Readmission Risk in Post-Acute Settings with Live Data

October 26, 2022 | Written by: Dr. Steven Stein, Chief Medical Officer

According to Statista Research Department, from the 3,046 hospitals Medicare assessed in 2022 for hospital readmissions, 2,499 (or 82 percent) were penalized for readmission rates exceeding the 30-day risk-standardized costs.

Readmissions are costly, often doubling the cost of care for one of these events. Preventable rehospitalizations cost Medicare hundreds of millions of dollars each year and can be avoided through better care and more attention to patients during discharge and transitions of care.

Decreasing hospital readmissions has been a long-standing health goal for CMS. It signifies an opportunity to improve the quality of care, lower health care costs, and increase member satisfaction simultaneously. Leading to the question, what can health plans do to better partner with their post-acute skilled nursing facility (SNF) network to prevent readmissions and improve other member outcomes while driving down costs?


Post-Acute Care’s Role in Reducing Readmissions

Currently, only the highest risk members are going to nursing homes after a hospitalization. This occurs when a health plan provider and physician have determined that the member could not safely transition from hospital to home, even with home care. The assumption is that an admission into a nursing facility is necessary due to the extra support needed (e.g., requiring around the clock nursing, more frequent involvement from a doctor and/or physical therapist, etc.).

Although readmission rates from nursing homes are still quite high (30-day risk adjusted readmission for FY2021 was 22% nationally), most would predict that if the same population went home, their readmission rates could be even higher. With the average Medicare costs of a hospitalization at $13,600, and the average Medicare cost of a SNF stay at $14,400, a health plan can ill afford to see its member be re-hospitalized for another $13,600. If you then add the cost of a second SNF stay and/or a home healthcare episode following the readmission, the preventable expenses can really mount up.


Working Better Together to Decrease Readmission Risk and Average Length of Stay

Due to an unprecedented high nursing turnover rate and an overall staff shortage of nurses and aides, more than ever, there is a significant benefit in having an extra set of eyes and ears to support the care of health plan members while in a SNF. If a health plan case manager (CM) can be alerted promptly when documentation by nursing home staff suggests the member may be at risk for a preventable hospitalization, the CM can engage with the nursing home staff or primary care provider to mitigate that risk. If that same CM has access to a thoughtful and real-time profile of the member at their fingertips (literally) on their phone or within their population health software product, the opportunity to efficiently intervene to prevent an unnecessary transfer is possible. Also, the ability for a plan provider to meet with a SNF and/or a SNFist on a monthly or quarterly basis to review readmissions and the alerts triggered 72 hours prior to the hospitalization makes such meetings much more impactful. It could lead to improved processes, customized training, and, eventually, better choices by the plan on which providers are utilized for its members.  It also is more likely that nursing home staff will review and heed such alerts if they know the plan will also be reviewing such alerts. (As they say, “You manage what you measure.”)

Additionally, having access to real-time outcomes on the health plan’s members in the facility allows a plan to reach swift conclusions in which facilities they want in their network. Instead of waiting for outdated claims data to arrive and then choosing to remove a poor performing facility, it can act more nimbly. Such information also enables better decision-making on which primary care provider they want their members to be seen by in each SNF. The variability in the quality of care and the frequency of visits by different providers can significantly drive outcomes, whether the staff at the facility are strong or weak clinically. The plan can also mandate that the docs that the plan contracts with (or drive business to) leverages the mobile app, thus having access to real-time alerts triggered at key interventional moments. Such a mobile app will also give the primary care physician at the nursing home (and their group’s covering docs) access to each member’s clinical information profile (e.g., vital signs, diagnoses, meds, recent alerts, etc.) when they are called by a nurse or proactively call a nurse after an alert was triggered.  An app can also be used to prioritize which members to round on and enable the physician to get “up to speed” on any recent changes in the member’s clinical condition(s).

It is not uncommon for health plan utilization management (UM) and CM nurses to not speak with each other, nor read each other’s notes. The UM nurse may gain information about a member’s stay that would be extremely valuable to the CM or vice versa. The success measure for a UM nurse is a lower SNF average length of stay (ALOS). The success measure for a CM is a reduction in readmissions. Sometimes, these goals can conflict with each other and need further discussion among the two health plan nurses. Many health plans will be satisfied if their UM and CM nurses get remote access to the SNF EHR. But will such access lead to timely interventions by a CM to prevent an unnecessary readmission? Or a UM nurse to reduce the often, non-valued added final days of a nursing home stay? Will a busy health plan nurse have the time to navigate all the nursing and progress notes, the therapy notes, the orders, the labs, etc. in the typical SNF EHR many times in a day or even once every day? If the health plan’s CM is alerted when the member is at significant risk for hospitalization and has access to a consolidated picture of what is happening with the patient in real-time, he or she can alter the course of an illness through the timely engagement of a SNF nurse and/or doctor. The UM nurse can leverage live data about functional status changes and medical stability to support appropriate transitions back to the community as soon as it is safe for the member to do so.


“Manage What You Measure” with Live Data

Real Time Medical System’s (Real Time) Interventional Analytics solution can help healthcare providers identify moments in a patient’s care that need immediate attention – through specified alerts triggered from troubling documentation in the EHR. Real Time can alert nursing staff and physicians to a subtle (or obvious) change in a patient’s condition prior to an adverse event that requires a transfer to the emergency room. Having easy access to each patient’s HIPAA-Secure consolidated medical record on a phone, tablet, or computer, any provider can efficiently review the patient’s conditions, meds, code status, etc. As well as call in orders to mitigate the risk of progression of the condition.

With the Real Time platform, health plans can also make better decisions regarding UM and help to better manage the SNF LOS. This live data enables both health plans and their post-acute partners to identify members who are medically stable enough and functioning at a high enough level to be discharged home. No longer does a health plan need to check in weekly when the visibility into the member’s status can be available 24/7 on the UM nurse’s phone, tablet, or computer.

Finally, the ability to view Real Time’s graphs and reports to see the performance of the nursing homes on a daily, monthly, quarterly basis, enables a health plan to make timely and informed decisions about their choice for an optimal network of facilities for their members. Being able to discuss alerts triggered within 72 hours prior to a readmission, and then discuss what was done to intervene at the time can lead to better understanding on why readmissions occurred and what could be done differently in the future. Having the capability to go into network meetings with that kind of knowledge really changes the ballgame regarding the kinds of meaningful conversations (and improved outcomes) that health plan and care providers can have on behalf of their shared patients.

If you have any further questions about the content of the article, please reach out to Dr. Steve Stein at [email protected].

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