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Originally published by Skilled Nursing News on July 26, 2021

Skilled Nursing News: What career experiences do you draw from most frequently in your role today?Scott Rifkin: I started as a patient. Due to chronic health issues, I spent much of my childhood and young adult life in and out of hospitals. I am also an internal medicine physician in practice for 25 years. Throughout my career, I became more involved in the operational aspects of nursing homes and spent years helping states on the East Coast bring facilities into regulatory compliance, helping them improve the quality of patient care.

Then in 2003, I bought Mid-Atlantic, a one-facility SNF. It grew into 21 facilities with more than 4,000 beds throughout the Maryland and Pennsylvania regions. As an owner and operator, I was looking for a better way to help these facilities and patients thrive. But I realized that we weren’t able to get the clinical insights from the data stored in the EHR to improve quality outcomes.

As an owner, I knew the challenges so many facilities faced extracting insightful data from EHRs and I knew that claims data wasn’t enough to really see what was happening in the moment with the patients’ care. So my team and I developed a unique platform to mine the EHR data deeper so that we could identify interventional moments based on live patient data, real-time patient data. And that’s how Real Time Medical Systems was born.

Our software pushes live clinical alerts to SNF care teams so they can track subtle changes in patient conditions and apply immediate interventions. Real Time also helped us harness live, actionable data so that we could better measure our performance under value-based care (VBC) models.

As VBC continues to evolve, I’ve also established value-based insurance plans, including institutional special needs plans in six different states.

What do you see in the skilled world today, and how is it changing in 2021?
Rifkin: The world of long-term care in nursing homes, and even of short-stay rehab care, is changing very rapidly. There’s a huge push by the federal government, by CMS, to have all nursing home patients in some form of value-based care, whether that means an ACO, a BPCI (Bundled Payment for Care Improvement) model, a Medicare Advantage plan or a Medicaid managed care program. There are organizations other than CMS that are going to look at how care is provided in nursing homes and evaluate them on all kinds of parameters that CMS has really never found a way to do themselves.

Those parameters include readmission rates and primary admission rates, plus length of stay, outcomes, and quality measures — all kinds of things that go into the decision process for a value-based provider to decide who they want in their networks. Hospitals are now taking downstream insurance risk more and more, they are looking at nursing homes to be high quality, low cost care partners.

What makes an efficient SNF partner?
Rifkin: When insurers and hospital systems see nursing homes with a high 22 or 23% readmission rate, they know there’s an opportunity to deliver better results — and they are looking for partners in the nursing home industry that can deliver those results, both clinically and financially. They’re not going to be all-inclusive the way Medicare has done in the past.

It’s already happening all over the country. Insurers, hospitals and ACOs are all creating narrower networks. With Real Time, the platform empowers nursing homes to become better partners who can reduce readmissions, lower the average length of stay, and improve conditions for the long-term care population.

The nursing homes with a value-based mindset that can demonstrate these types of results will gain hospital referrals. There’s no question the successful nursing homes are those that can trade length of stay for volume and keep patients from being readmitted to the hospital. That’s the wave of the future.

The good news is that the data is there to make that a reality. We’ve helped many SNFs gain not only better clinical line of sight into their patient population, but we’re also using live analytics in the form of dashboards and reports to help them gain a broader but deeper view across the population and across multiple facilities.

What are some top strategies that skilled nursing providers can take to be part of that future?
Rifkin: During my time at Mid-Atlantic, I approached our hospital systems, ACOs, local insurers, national insurers and Medicaid and Medicare insurers and said, “We want to be your best provider. We’ll work really hard to better manage length of stay and reduce readmission rates, but give me volume in exchange.” Believe me, they’ll want to do it.

But to be successful, facilities have to be able to show them the data to support their claims. And all of Real Time’s clients have the data to support these claims — it’s part of what we do for them. Because the data demonstrates that they can manage patients better, they use it in their marketing and contract negotiations to make sure they’re never left out of a network.

That’s the biggest tragedy for any nursing home operator today: to have an entity develop a preferred network of nursing homes and not be included.

For example, one of Mid-Atlantic’s partners was taking a huge amount of risk with a managed care Medicare entity. We went to that insurer and offered to take a case rate to manage the patients and get them home within 15 days. They agreed to give us the volume and we took risk on the length of stay.

What happened? We doubled our volume and dropped our length of stay on those patients from 21+ days to about 11 days. The readmission rates actually went down. We ended up with a Medicare average rate of about $800 a day. That’s pretty darn good in today’s world.

What are the simple ways that Real Time helps SNFs identify the types of patients who will be best for this approach?
Rifkin: SNFs have to be able to market their success: readmission rates, hospital days per thousand in the long-term care population, length of stay, patient satisfaction and quality measures.

Good data analytics software finds SNFs at-risk patients and identifies those interventional moments. Instead of traditional predictive analysis that only examines standard EHR data, Real Time analyzes live structured and unstructured data as it is entered into the medical record in real time. We look at hundreds of potential interventional moments. If the SNF picks up on them as a change in condition occurs, instead of trying to predict what could happen based upon historic data that could be days or weeks old, they improve care outcomes and keep people from being admitted.

This way, clinical staff members are not surprised when patients get sick, but instead, can treat them two or three days earlier before their conditions worsen. It flat out works.

In organized programs where an operator or an ACO or a health system has used Real Time and put some clinical people behind it, they cut the readmission rates in half, from the low 20s to 10 or 12%. We have several facilities that are even down in the 10-11% range.

How specifically does interventional analytics work?
Rifkin: Nursing homes today have these great medical records with lots of data, and they’re not using them to effectively monitor patient care in a timely manner. For example, when surveyors come in, they don’t give a facility an immediate jeopardy or a G-level deficiency because Mrs. Jones fell and broke her hip. They gave that high-level deficiency because they believed there was something in the medical record that the facility should have seen that would have been used to prevent that fall.

But interventional analytics would have pointed out something in the chart three days earlier, so the SNF could immediately see it, and would have prevented her fall.

To give an example: Mrs. Jones gets up out of bed, walks seven steps down the hallway, falls and breaks her hip. In the chart a nursing aide wrote, “Mrs. Jones was a little dizzy this morning.” The next day, someone else writes, “Mrs. Jones isn’t drinking and eating really well.” The chart also shows that instead of her blood pressure being her normal 130 over 70, it is 105 over 70 — not necessarily abnormal, but low for her.

A surveyor puts A, B and C together and indicates, “Mrs. Jones was dehydrated, dizzy, fell down and broke her hip, and you now have a G-level deficiency.”

Instead, with interventional analytics pulling live data from the EHR, including narrative notes, SNFs can be alerted to those subtle changes in Mrs. Jones’ chart. Our software mines live information from the EHR and uses comprehensive algorithms to compare current status to an established 72-hour baseline of the patient’s clinical condition upon arrival at the facility. The platform then sends clinical alerts and suggested interventions based on standards of care. Armed with this live information, clinicians can take immediate action to improve Mrs. Jones’ condition – keeping the SNF three steps ahead of that fall and three steps ahead of the surveyor.

Clearly there are clinical benefits to data analytics software in skilled nursing. Are there economic benefits as well?
Rifkin: There are. Throughout the industry, data analytics inspires new ways to solve problems. It saves time and money, reduces regulatory exposure, and most importantly, improves patient outcomes.

The right software can help SNFs increase occupancy while better managing length of stay and improving key quality metrics around readmissions, patient safety, and satisfaction. There’s financial value too. Real Time’s software has the ability to look for missed IPA (Interim Payment Assessment) coding opportunities and verify the accuracy of initial PDPM assessments. The typical facility we work with sees an average of $30.65 PPD (per patient day) in additional revenue by being more accurate with their PDPM initial assessment and $35.59 PPD for IPA submissions.

Equipping the facility with proven data can also establish it as a key asset and better provider partner for payers — the risk-taking entities that are now dominating value-based care in this country. With increased referrals, that facility will become a more relevant provider, but most importantly, will remain a vital part of the healthcare continuum within the local community.

Entering this year, no one knew fully what to expect about how 2021 would play out. What has been the biggest surprise to you this year in the skilled nursing industry, and what impact do you think that surprise will have for the remainder of the year?
Rifkin: The biggest surprise is the continued decline in nursing home occupancy and census. But with that comes opportunity. I think COVID has given the whole health care world an opportunity to rethink business models. There’s a real moment of reset here. Health systems are doing it, insurers are doing it, the savvier nursing home operators are doing it.

There is no question that value-based care will push forward. If SNFs don’t change their mindset and show the true value that nursing homes provide, they’ll miss the opportunity to participate in the patient care continuum. Skilled nursing facilities have the chance to become stronger partners by enhancing operations, dramatically improving care and building relationships with their biggest admitters and insurers. The time to do it is now.

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