Real-Time Data: Enhancing Payer Contracts in Post-Acute Care Settings

Payers face limitations when relying too heavily on claims data for managing care and selecting partners in post-acute care settings. Claims data tends to be outdated and lacks sufficient detail.

That detail comes from real-time information and interventional analytics that can help payers create post-acute networks that offer unique advantages to providers and patients, most notably the ability to identify high-risk individuals upon entry to a skilled nursing facility or long-term care home.

Real-time data also allows for timely interventions by nursing home staff, physicians, and health plans to prevent unnecessary hospitalizations or emergency room visits. Additionally, real-time information helps determine appropriate length of stay by considering factors like physical and cognitive functioning and community resources when determining the right time for a safe transition back to the community or the long-term care part of the facility, thus reducing unnecessary nursing home days and associated costs to the plan.

Moving from historical to real-time data

Interventional (i.e., real-time) analytics enables impact at the individual level without the need to navigate fragmented nursing home electronic medical records.

The difference between traditional and interventional analytics lies in their focus and application. Based on historical data, traditional analytics are useful for population-level predictions but may not effectively address individual health statuses, especially for rapidly changing conditions. On the other hand, interventional analytics utilizes live data from post-acute electronic medical records to intervene and modify outcomes in real time, providing timely information for care decisions and avoiding unnecessary hospital readmissions.

Data captured via claims or the nursing home’s minimum data set (MDS) arrive too late, preventing opportunities for impactful clinical interventions.

“MDS data often isn’t available until somewhere between the 14th and 21st day at the facility for new nursing home residents, and the MDS assessment tool is, most often, only done quarterly for the long stay residents in the building, which is way too late to act on that information or even measure how the facility is performing in the recent months,” stated Real Time Medical Systems’ Chief Medical Officer, Dr. Steven Stein.

By receiving alerts based on real-time information, nursing home staff, physicians, and health plans can intervene to prevent unnecessary hospitalizations or emergency room visits. Additionally, real-time information assists in determining the most appropriate length of stay for residents.

According to Stein, factors such as physical and cognitive functioning, as well as available community resources, can be assessed to decide when it is safe for a person to transition to the next level of care. This insight helps avoid unnecessary nursing home days and associated costs, as some individuals may be better suited for care at home or in the long-term care part of the nursing home.

“When payers and post-acute care settings lack a real-time source of information, they cannot have meaningful conversations about care strategies,” Stein maintains. “More sophisticated health plans will work to ensure that real-time data informs the plan and their post-acute network on targeted ways they can improve quality and utilization outcomes. This data also makes health plans more nimble in determining which facilities remain in their networks. And by sharing performance data with their provider partners and even reviewing cases that appear to showcase opportunities for improvement, the health plan supports a more accountable relationship with their contracted facilities that adds value to some of their most vulnerable members.”

Key characteristics of a high-performing SNF

Payers often prioritize specific characteristics when evaluating SNFs and post-acute care facilities. The primary consideration is the cost of the episode of care, which indirectly reflects the quality of care provided. This cost includes not only the expense of the nursing home stay but also any subsequent readmissions to the hospital that occur in the subsequent week or weeks following discharge from the SNF.

In addition to cost, Stein highlights key metrics payers must use to determine the value and effectiveness of SNFs other than the episodic cost of care:

Direct SNF to inpatient readmissions: Outside likely of the readmission rate, a plan should also evaluate the timing of the readmissions. Readmissions in the first few days of admission to the SNF likely significantly contribute to this undesired outcome. As the stay gets longer, the nursing homes quickly increase their accountability for minimizing preventable hospitalizations.

Length of stay in the nursing home: Payers evaluate the duration of member stays in the nursing home. A shorter length of stay can indicate efficient care delivery. When the post-SNF discharge readmission rate back to the hospital remains low, it suggests efficiency is also complemented by strong transition planning. It implies that members’ needs are effectively addressed, enabling them to transition back to the community safely.

Readmissions following the nursing home stay: The occurrence of readmissions after members leave the nursing home and return home is a crucial metric. High readmission rates may indicate premature discharges, less than optimal discharge planning, or a poorly performing home care agency network.

“While the episodic cost of care is an important metric, it should be considered indirectly, as a reflection of quality, based on prolonged nursing home stays due to preventable complications and/or high readmission rates. The literature supports the fact that most readmissions from the nursing home to the hospital are preventable.” Stein stresses.

The need for engagement

Leading health plans place a high value on working closely with the variety of providers comprising the workforce of SNFs and post-acute care settings. Technology — particularly real-time information and interventional analytics — is key to supporting physicians, physician assistants, and nurses in these increasingly important care settings.

By leveraging real-time information, both payers and post-acute care providers can have a direct impact on improving care at the bedside. Doing so has recently become a top concern in light of changes to the healthcare workforce. Due to staff turnover and inconsistency in care providers, subtle changes in residents’ conditions may go unnoticed. Nurses may not receive adequate communication or be able to evaluate the situation themselves.

By providing real-time information and alerts, there are opportunities for nurses and doctors to make timely and meaningful interventions. This mitigates the risk of readmissions by addressing changes in condition at an earlier stage of acuity.

Opportunities for contracting

Real-time data also plays a significant role in improving payer contracts with SNFs and post-acute care facilities.

According to Stein, payers can use real-time data to financially incentivize favorable outcomes, such as reducing readmissions where SNFs receive bonuses closer to the period in which they delivered those favorable results. Studies have shown that the farther away the incentive is received from the outcomes that led to the bonus, the less likely the provider will alter their care. Payers can continue to drive incremental revenue and strengthen partnerships with nursing homes by selecting SNFs that deliver excellent care and allowing them to share in the benefits. Shared benefits create opportunities for nursing homes, particularly where facilities may not be fully occupied. Timely incentive payments for a low monthly or quarterly readmission rate produce results that benefit the SNF, the health plan, and most importantly, the patient.

Similarly, payers can also decide to financially incentivize treating physicians, nurse practitioners, and PAs at the SNF to utilize a real-time data solution to drive down readmission rates. By relying on timely data, providers can deliver better care at the bedside. Moreover, health plans can set expectations for product utilization in care delivery, fostering collaboration between healthcare providers and the health plan to improve patient outcomes.

Additionally, payers can use real-time information in their contracting to align all stakeholders— members, providers, and payers. Real-time data enables payers to monitor and assess the quality of care provided by SNFs, leading to more informed and timely contracting decisions and improved care outcomes. It also encourages compliance with agreed-upon practices and protocols.

Conclusion

Leveraging real-time information and interventional analytics in payer relationships with SNFs and post-acute care settings brings significant advantages to care management of members transitioning to their homes. Collaboration between payers and SNFs, based on shared data and financial incentives, strengthens partnerships and improves the overall quality of care for the payer’s members.

By overcoming the limitations of basing decisions on old claims data and utilizing real-time information, payers can identify high-risk individuals, intervene to prevent unnecessary hospitalizations, and determine appropriate length of stay by giving providers tools aligned with their workflows and their mission to improve the health and well-being of individuals and populations.

_____________________________

About Real Time Medical Systems

Real Time Medical Systems is the KLAS Rated, HITRUST-Certified Interventional Analytics solution that turns post-acute EHR data into actionable insights. Serving healthcare organizations nationwide, Real Time improves value-based outcomes by reducing hospital readmissions, accurately managing reimbursements, detecting early signs of infectious disease, and advancing care coordination through post-acute data transparency.