Setting the Value-Based Care Stage Across the Continuum

February 8, 2023 | Written by: Real Time Medical Systems

During a recent webinar hosted by Real Time’s partner, Relias, Executive Vice President of Health Systems Solutions Phyllis Wojtusik, RN, and Senior Clinical Account Manager Kathy Derleth, RN, BSN, discussed what value-based care (VBC) means for both acute and post-acute partners, and why communication, care coordination, and collaboration are vital to attaining VBC goals. Phyllis and Kathy also highlighted the benefits of utilizing live data and post-acute analytics tools to offer more effective care transitions, standardized clinical pathways, risk stratification, lowered length of stay (LOS), and reduced readmissions — all of which equate to reduced costs for acute care providers, increased referrals for post-acute facilities, accomplished VBC initiatives, and, most importantly, improved patient care.

Below are some key takeaways from this discussion.


The Long Road to Value-Based Care for Acute and Post-Acute Providers 

Within VBC, healthcare partners are incentivized based on the quality of care they provide to patients. Therefore, VBC models revolve around the patient’s treatment and how well a coordinated care team can improve patient outcomes based on certain metrics, such as reducing hospital readmissions, improving preventative care, and enhancing transitions of care throughout the care continuum.

With CMS’ announcement of the ambitious goal of having all members with traditional Medicare in an accountable care relationship with a healthcare provider by 2030, now is the time for acute and post-acute providers to take the necessary steps to collaboratively work together and participate in VBC programs. Quality metrics and measures are a key driver in achieving VBC through measuring readmissions, LOS, continuity of care, days spent in a community, medication adherence, and routine diagnostic testing.


Create an Optimal Post-Acute Network to Drive Better Patient Outcomes 

Having a post-acute network (PAN) is critical to a care provider and patients’ success, particularly when 49% of all post-acute care (PAC) costs come from Skilled Nursing Facilities (SNFs). Developed by acute care entities and Accountable Care Organizations (ACOs) to oversee quality and performance of the post-acute continuum, PAN strategies are instrumental for success. Some of these strategies include case management, clinical pathways to standardize care processes, care transitions, and yearly network performance review.

When SNFs have a VBC focus for patients within the network, care providers can maintain census while reducing readmissions (including LOS and Advance Practice Providers). Network partners can also facilitate effective care management, including transitions of care, discharge preparation and management, and manage chronic disease, as well as optimize reimbursement with Quality Improvement Program (QIP) incentives (quality metrics, immunizations in 2023, share best practices).


Advance Value-Based Models for Effective Clinical Pathways with Post-Acute Data Analytics

By accessing live data analysis within the EHR, post-acute providers can immediately identify patient care needs and be proactive rather than reactive in the outcomes provided. Typical health data management looks back on patient care, (i.e., MDS data tends to be 30-90 days old and claims data can be 3-9 months old), as well as CMS Stars data taking upwards of a year to alter rating.

However, this all changes with the use of real-time data and maintaining a forward-thinking outlook on patient care. Live data can be directly pulled from the post-acute EHR, providing patient level impact, including insights into care outcomes. By employing this data, providers, both acute and post-acute, can see how a facility is performing in the moment, receive changes in strategy and operations, partake in root cause analysis at the patient and system level, and view the same data for QAPI metrics and performance indicators.


Provide a Patient-Centered Referral Experience

Providers can prioritize care by delivering a patient-centric approach for referrals within the network through the use of live post-acute data analytics. This can be accomplished by enacting clinical care pathways with suggested interventional strategies, maximize supervisor oversight, and identify patients that require late loss ADL support. Care partners can also improve transitions of care and discharge planning by developing a VBC mindset among all providers. When partners set collaborative goals, benefits across the network begin to form – including coordinated clinical information and communication, Advance Care Planning, transitions of care, and setup for successful discharge to the community.

As VBC programs continue to dominate the traditional fee-for-service care delivery models, now is the time for care providers to establish themselves as essential healthcare partners. VBC is here to stay and aligning acute and PAC initiatives to deliver better clinical and financial outcomes will prove beneficial across the entire patient continuum. Through the use of live, post-acute data analysis such as Real Time’s Interventional Analytics, providers can connect to the patient’s post-acute care journey by being alerted earlier to a change in condition, allowing for timely interventions, as well as share key insights with referral partners, and improve patient outcomes. To learn more about how solutions like Real Time can help achieve value-based goals, contact us today.


And in case you missed it, you can access and view this on-demand webinar here!

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