The value of real-time interventional analytics in reducing hospital readmissions and improving member outcomes
May 19, 2025
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This article was originally featured in Fierce Healthcare.
According to the Centers for Medicare & Medicaid Services (CMS), nearly 20% of members admitted to skilled nursing facilities (SNFs) for rehabilitation following acute medical events are readmitted to the hospital within 30 days. These avoidable readmissions not only pose serious health risks to beneficiaries but also impose a significant financial burden — costing Medicare over $5 billion annually.
For payers operating within value-based care models, reducing readmissions is a critical lever for improving both financial performance and member outcomes. One of the most effective approaches to address this challenge is through the implementation of interventional analytics — technology that delivers real-time, actionable insights to proactively mitigate risks before costly complications arise.
How Real Time’s interventional analytics platform works
Real Time Medical Systems’ (Real Time) interventional analytics platform continuously harnesses live data from the post-acute EHR, using proprietary algorithms to identify members at risk for hospital readmission. A dynamic keyword search function scans for more than 400 clinical indicators that may signal an impending adverse event leading to rehospitalization. When risk is detected, an alert is sent to care teams along with recommended actions, enabling timely, targeted care interventions to prevent further decline.
“Real Time’s data-driven technology detects subtle changes in condition that might otherwise be missed,” says Phyllis Wojtusik, RN, Executive Vice President, Value-Based Care at Real Time. “It gives the care team a chance to take action before a small issue turns into a costly hospital transfer.”
Take, for example, a member with a history of congestive heart failure (CHF) who is admitted to rehabilitation following a hip replacement and begins to retain fluid and experience shortness of breath. The care team would receive real-time alerts recommending specific actions based on clinical guidelines from the Post-Acute and Long-Term Care Medical Association (PALTmed), formerly known as AMDA, and Interventions to Reduce Acute Care Transfers (INTERACT). These interventions are designed to prevent full pulmonary edema — a life-threatening complication that would likely result in rehospitalization.
Quantifiable results that align with payer priorities
A 2024 study published in the American Journal of Managed Care highlighted the measurable impact of Real Time’s interventional analytics platform on member care in the post-acute setting. The study compared CMS-based quality measures and rehospitalization rates among SNFs within Penn Medicine’s Lancaster General Hospital (LGH) system using Real Time’s interventional analytics platform against LGH-affiliated SNFs that were not using the solution. Results were also compared to state and national benchmarks.
The findings were compelling:
- Readmission rates in SNFs using Real Time’s interventional analytics were 15% lower than national averages, 12% lower than Pennsylvania averages and 13% lower than LGH SNFs not using the platform
- Facilities using interventional analytics outperformed all comparison groups across four CMS-based quality measures:
- Risk-standardized potentially preventable readmission rates
- Medicare spending per beneficiary
- Infection-related hospitalizations during SNF stays
- Successful discharge to home or community (56.9% for interventional analytics SNFs vs. 52.5% nationally)
For payers, these transformative improvements represent substantial gains in cost efficiency, quality performance and member health outcomes.
Enabling scalable, system-wide impact
For instance, when a hospital has specific protocols for post-operative recovery — such as early mobility following orthopedic surgery — Real Time’s platform ensures that SNF partners are aligned and consistently following those care standards. This enables shared accountability, real-time progress tracking and smoother care transitions from hospital to SNF and back home. Additionally, payers can monitor what’s going on in real-time, providing an extra layer of support and oversight.
The data analytics platform also enables live risk stratification across beneficiary populations, allowing care teams to proactively focus immediate attention on those at highest risk, reduce length of stay and identify those ready for safe discharge sooner.
Customer data collected by Real Time shows, on average, users experience:
- Up to a 50% reduction in hospital readmissions
- Up to a 40% reduction in post-acute length of stay
A strategic asset in value-based care models
In nursing facilities with 100 or more members, manual chart reviews are neither scalable nor sustainable. Interventional analytics brings critical “interventional moments” to the surface, allowing care teams to act early and decisively — improving quality while managing costs.
“Analytics and interventional moments enable members to go through their course of care as quickly as they can with the best outcomes they can achieve — so they can go home,” says Wojtusik. “That’s critical, because preventing bad outcomes isn’t just about reducing costs. It’s about doing the right thing for members.”
For payers committed to performance in value-based care models, interventional analytics is more than just a clinical tool — it’s a strategic asset that improves quality, lower costs and enhances the member experience in the post-acute setting.