Why health plans need post-acute directors of nursing as clinical partners in value-based care
This article was originally featured in Fierce Healthcare.
As the transition to value-based care (VBC) continues to present both opportunities and challenges, post-acute care (PAC) remains a significant cost driver for health plans. Traditionally overseen through administrative channels, it’s increasingly clear that health plans operating in today’s VBC landscape need a more innovative approach to managing post-acute spend – one that leverages a critical, yet often overlooked, clinical partner: the Post-Acute Director of Nursing (DON).
DONs represent a largely untapped resource for health plans aiming to improve outcomes and control costs among their most vulnerable member populations.
One of the key challenges in VBC is influencing clinical outcomes within post-acute facilities, where health plans typically have limited direct oversight. Traditional care management strategies often rely on administrative coordination and periodic check-ins, creating a disconnect between health plan objectives and the realities of bedside care.
DONs are uniquely positioned to bridge this gap. With clinical expertise and operational authority, they can interpret member conditions, adjust care plans in real-time, and directly engage with the nursing staff who provide round-the-clock care. Unlike administrative personnel, DONs have the clinical insights and proximity needed to make timely, informed decisions.
The stakes are high. According to CMS’s Skilled Nursing Facility (SNF) Value-Based Purchasing Program, nearly a quarter of Medicare beneficiaries discharged to SNFs are readmitted to the hospital within 30 days – a rate that poses both a quality concern and a financial risk under VBC contracts.
The disconnect between care management strategies and clinical execution at the facility level often results in missed opportunities for early intervention. While care coordinators may identify potential issues through data, they frequently lack the clinical proximity, authority, and timeliness to act effectively. In contrast, post-acute DONs possess all three – and are equipped to recognize and respond to emerging warning signs before they escalate.
The limitations of health plans’ current post-acute coordination strategies
Most health plans manage post-acute care coordination through traditional channels – primarily relying on social workers and discharge planners who focus on placement logistics and psychosocial needs. While these professionals play essential roles, they often lack the clinical authority and real-time visibility needed to effectively prevent readmissions.
The financial impact of this gap is substantial. CMS estimates that hospital readmissions cost Medicare nearly $30 billion annually, highlighting the immense economic burden of preventable hospitalizations. For health plans operating under value-based contracts, each avoidable readmission not only strains financial resources but also negatively affects quality ratings and member outcomes.
Common strategies also depend heavily on delayed data and reactive interventions. By the time health plan teams identify concerning trends, the critical window for intervention may have already passed. In contrast, when paired with live analytics and clinical alerts, post-acute DONs are positioned with the right information at the right time to respond immediately and proactively intervene – preventing adverse events and costly readmissions.
“Readmission costs can be significantly reduced when the DON leverages live data analytics to identify high-risk members and respond to subtle clinical changes. With the support of technology, the DON can intervene in care at the right moment with the appropriate treatment – keeping members on track and avoiding unnecessary transfers.” – Phyllis Wojtusik, RN, EVP of Value-Based Care at Real Time
How health plans can leverage real-time data to empower DON partnerships
Real Time Medical Systems’ (Real Time) interventional analytics platform bridges a critical gap between health plans and clinical decision-makers at the post-acute point of care. Unlike retrospective data analysis, the SaaS delivers real-time insights directly to DONs, enabling them to act immediately on changes in member conditions.
The platform continuously monitors both structured and unstructured data from post-acute EHRs, using proprietary algorithms to detect subtle clinical changes as they occur. When risk factors emerge, DONs receive instant alerts with specific, evidence-based intervention recommendations – grounded in standardized care pathways such as PALTmed and INTERACT protocols. This ensures not only timely action but also consistency in clinical decision-making across facilities.
For health plans, Real Time provides unprecedented visibility into the live clinical status of members in post-acute settings. Rather than reacting to complications after emergency visits or readmissions, health plans can support proactive interventions that reduce costly escalations and improve outcomes.
CMS estimates the overall 30-day hospital readmission rate among Medicare beneficiaries to be approximately 14.7%, with significantly higher rates among vulnerable populations such as dual-eligible individuals and those with chronic conditions. Research shows that improved care coordination and discharge planning can help reduce these rates. Real Time’s platform has demonstrated even greater impact – facilities using it have achieved up to a 50% reduction in hospital readmissions and a 40% reduction in post-acute length of stay.
“DONs lead care processes within the facility and serve as the primary communicators with staff and providers. They play a central role in coordinating all contributors to care and ensuring the treatment plan stays aligned with member needs.” – Phyllis Wojtusik, RN, EVP of Value-Based Care at Real Time
For health plans, this translates directly into improved HEDIS scores, reduced medical costs, and enhanced member satisfaction.
Building health plan-DON partnership models that drive results
Successful partnerships between health plans and DONs are built on structured frameworks that align incentives and foster shared accountability for outcomes.
The most effective models establish clear communication channels between health plan care managers and post-acute DONs, enabling real-time collaboration on high-risk members. While shared savings arrangements can help reinforce alignment, the most meaningful connection for DONs lies in clinical goals – such as reducing readmissions, improving outcomes, and ensuring continuity of care. When these goals are clearly defined and supported by structured processes, DONs are empowered to lead interventions that directly impact VBC success.
Technology platforms such as Real Time facilitate these partnerships by providing both health plans and DONs with shared visibility into member conditions and outcomes. Health plans gain real-time insights into clinical status, while DONs are empowered to act immediately – leveraging live data and decision-support tools to optimize care delivery.
“Effective partnerships between DONs and health plans are built on mutual accountability, standardized communication, and a shared commitment to clinical care standards. Real Time’s platform empowers both sides to collaborate around the same actionable data – creating true alignment in improving care delivery and outcomes.” – Kristen Klopp, RN, Customer Success Manager at Real Time
Importantly, the long-term benefits of these partnerships extend well beyond cost savings. Health plans that collaborate effectively with DONs can expect measurable improvements across key VBC metrics, including reduced readmissions, higher Star Ratings, improved member satisfaction scores, and enhanced clinical outcomes.
The strategic imperative for health plans
As VBC models become more prevalent, health plans can no longer rely solely on traditional administrative coordination. The clinical complexity of post-acute populations demands partnerships with decision-makers who possess both the expertise and authority to drive real-time improvements.
DONs represent the most effective path to influencing clinical outcomes in PAC settings. By partnering with DONs and equipping them with real-time data, health plans can shift from simply managing costs to actively preventing them.
Real Time has already demonstrated measurable impact, including significant reductions in hospital readmissions from PAC. For health plans operating under increasingly stringent value-based contracts, these improvements can be the difference between financial success and failure.
The time to act is now. As PAC costs continue to rise and quality expectations grow, health plans that build strong clinical partnerships will gain a meaningful competitive advantage over those that continue to rely on outdated administrative approaches.
For more information, visit www.realtimemed.com.