To succeed in value-based care, health plans and risk-bearing entities — such as accountable care organizations (ACOs) and providers in risk-based agreements — must create cost savings while improving health outcomes. With care outcomes on the line, every step of the member journey matters.
Traditionally, post-acute care has been a notoriously difficult step to navigate. Low visibility for health plans and payers has created challenges in care management. Moreover, participation of skilled nursing facilities (SNFs) in value-based care programs is limited. Less than 10% of SNFs participate in an ACO nationwide, and nearly 70% of all ACOs have no SNF participation.
To meet this challenge, Mission Health Coordinated Care, a Medicare Shared Savings Plan ACO under St. Joseph's Health, utilized interventional analytics and live member data combined with a care management team. The results of this intervention, published in "Management in Healthcare", led to significant cost savings and a reduction in readmissions — promising findings in light of the industry's shift toward value-based care.
Vulnerabilities in post-acute care
For health plans, post-acute care represents a critical point in the member journey that can lead to costly readmissions if not managed effectively. With 47% of inpatient hospital discharges followed by post-acute care services, vulnerabilities in this area can significantly impact a health plan's bottom line.
The Centers for Medicare & Medicaid Services (CMS) reports that 15% of members discharged to SNFs are readmitted to the hospital within 30 days. Nevertheless, researchers estimate that 1 in 4 of these readmissions could be potentially preventable.
Historically, health plans and health systems have struggled to find reliable means of tracking members in the post-acute setting and intervening in care to improve outcomes. Traditional care management practices in this area rely on outdated data sources to predict potential issues and mitigate risks. However, retroactive data analysis falls short in guiding real-time member care management.
Case study: St. Joseph's Health
St. Joseph's Health, a prominent health system in New Jersey, faced significant challenges in managing its post-acute care population. Without access to live member data, its clinical teams could not proactively monitor outcomes or coordinate care effectively. Cumbersome manual data collection and entry pulled clinical teams away from member care without providing meaningful insights. This lack of visibility led to high readmission rates — 24% for members in their ACO, Mission Health Coordinated Care.
Additionally, St. Joseph's Health struggled to reach the full potential of its high-performing network of SNFs and home health providers. With outdated performance metrics based on Medicare star rating and claims data, the implementation of performance improvement plans and changes in network participation were slow and ultimately ineffective.
The solution: Care navigation powered by real-time data
To address these challenges, St. Joseph's Health brought on a post-acute care nurse navigator dedicated to monitoring members transitioning to SNFs, along with a social worker and a case manager. They equipped this team with a powerful data analytics platform that provided real-time access to member records in post-acute facilities. This access enabled unprecedented care coordination, including daily monitoring of member progress and early identification of potential readmissions.
Interventional data analytics played a pivotal role in transforming post-acute care at St. Joseph's Health. The data platform provided live readmission risk scores, detailed reports, and staff alerts for timely interventions. This live data enabled clinical teams to intervene early, preventing unnecessary readmissions and ensuring appropriate lengths of stay.
This intervention was further enhanced by optimizing the utilization of St. Joseph's Health's high-performing SNF network. Data sharing between the network and St. Joseph's Health was expanded, and real-time data analytics facilitated meaningful network performance reviews and participation decisions.
Post-acute care involvement in value-based care is relatively new, and facilities may encounter barriers to meaningful participation. St. Joseph's Health discovered that clear goals and incentives — such as improvements in star ratings, clinical outcomes, referral rates, reimbursements, and potential shared savings — were critical for driving SNF engagement and collaboration within its high-performing network. Live data allowed St Joseph Health to effectively demonstrate these benefits to its SNF partners, further improving quality of care.
The outcome: Significant cost savings and fewer readmissions
This solution yielded remarkable results. In the program's first year, St. Joseph's Health saved $1.6 million in post-acute network spending, effectively offsetting the costs of implementing the program multiple times over.
Additionally, readmission rates decreased from 24% to 17.8% in the first year and fell even further — to as low as 13.6% — in subsequent years. The average length of stay was reduced from 24.8 days to 21.6 days, resulting in further savings and improved quality of life for ACO members. Due to this success, St. Joseph's Health expanded the program to include all members in value-based contracts.
In St. Joseph's Health's high-performing SNF network, enhanced data transparency and communication between acute and post-acute care providers fostered a genuine collaborative partnership, leading to enhanced member satisfaction and better clinical outcomes.
The results of the program garnered national recognition. For its excellence in member outcomes, St. Joseph's Health was awarded the 2022 NAACOS Leaders in Quality Excellence Award.
The case of St. Joseph's Health illustrates how real-time data can profoundly impact post-acute care management. With the right data partner, such as Real Time Medical Systems, health plans and health systems can leverage live member metrics and equip care management teams with powerful interventional analytics to significantly improve outcomes and reduce costs. As value-based care continues to grow, adopting these data-driven strategies will be essential for achieving success in the future of post-acute care.
