St. Joseph’s Health System Reduces Readmissions, Saves $1.6M in First Year Thanks to Live Post-Acute Patient Data

St. Joseph’s Health System, a leading provider serving New Jersey and the New York metropolitan area, participates in the MSSP Accountable Care Organization (ACO) and Bundled Payment for Care Improvement-Advanced (BPCI-A) models for Medicare patients. As part of these value-based care initiatives, the health system needed to reduce readmissions from its expanding skilled nursing facility (SNF) network. Without visibility into patients’ daily progress after transitioning to post-acute care, they relied solely on admission, discharge, and transfer (ADT) feeds, as well as claims data—all reactive and often delayed. The implementation of Real Time’s live post-acute analytics solution gave St. Joseph’s real-time insight into SNF patient care, enabling proactive intervention and improved care coordination.

Key Takeaways:

• Access to live post-acute data improved care coordination and reduced readmissions, helping St. Joseph’s lower its rate from 24% to 17.8% while enhancing visibility into patient progress across nine connected facilities.
• Leveraging Interventional Analytics for smarter decision-making and financial oversight allowed the health system to monitor clinical necessity, manage lengths of stay, and identify high-performing SNFs for increased referrals.
• Collaborative relationships with post-acute partners was strengthened with live post-acute data by fostering trust, two-way communication, and a unified approach to delivering value-based care.

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