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Originally published by Becker’s Healthcare on June 3, 2019

Skilled nursing facilities and hospitals had been at odds over approaches to post-acute care.

However, as payers tie reimbursement to outcomes-based data and SNFs begin to adopt CMS’ new Patient-Driven Payment Model, it’s more important now than ever before for hospitals and SNFs to develop a collaborative post-acute care environment.

Real Time Medical Systems’ Founder and Executive Chairman Scott Rifkin, MD, and Executive Vice President Phyllis Wojtusik, RN, explored how their interventional analytics platform ignited collaboration between hospitals and post-acute care communities and reduced readmissions saving hospital’s millions of dollars in value-based care programs during the May 23 webinar hosted by Becker’s Hospital Review and sponsored by Real Time Medical Systems.

When it comes to cutting readmissions, noticing symptoms within a day or two is essential. Seventy percent of patients in SNFs could avoid readmission if SNF staff were able to understand their symptoms earlier, Dr. Rifkin said.

Dr. Rifkin shared an example. Imagine a patient who had a previous history of heart failure. While staying at the SNF following their hip replacement, the nurse documented that the patient had swollen feet. Because the previous history of heart failure was buried so deep into the medical record, the caregiver didn’t see the patient’s previous heart failure condition and only documents that the patient has swollen feet.

“They aren’t able to put A and B together, so that patient with a history of heart failure who now has swollen feet … is the same patient that ends up in your emergency room with pulmonary edema three days from now if we don’t do anything about this,” Dr. Rifkin said. “For a $1 worth of generic Lasix, it could’ve prevented a $20,000 hospital stay if you can easily detect this information within the EMR ahead of time.”

Properly documenting symptoms and the diseases they correlate to is essential — but more importantly, being able to retrieve the buried data within the EMR in real time, is imperative to fighting readmissions. In 2010, Dr. Rifkin did something about it.

At the time, he owned and managed 21 SNF facilities, so he went to his EMR provider with 300 diagnostic questions he wanted the system to ask every day. The provider said sure, but it would take 300 individual reports to answer them.

Unsatisfied with that administrative burden, he formed his own platform, which became the Real Time platform. The platform runs 300+ queries every shift on every patient. It requires next to no technical or IT support and inhouse administration can support the platform.

The platform reads every data point in the chart looking for interventional opportunities. It then pushes the interventional opportunities to the charge nurses, DONs, NPs and doctors. The opportunities are paired with standard national protocols for the healthcare staff to use for intervention.

Based off the LACE tool, the platform features the latest national intervention guidelines and categorizes patients by risk. At a glance, SNF administrators can see the readmission risk status of every patient color-coated by risk, and individual caregivers can get personalized treatment recommendations to prevent readmissions.

When Dr. Rifkin implemented it across his SNF facilities, readmissions dropped from 22 percent to 8 percent. He knew it was something that worked, as did Ms. Wojtusik, who worked at a 663-bed health system in Pennsylvania when she first heard about it.

Added benefits
In her position with the hospital, Ms. Wojtusik led care improvement efforts. The three-hospital system had more than 35,000 annual discharges with an average of 3,000 to 4,000 patients discharged to SNFs. The hospital’s post-acute care costs were almost double than the national average, caused by longer lengths of stay.

In 2016, the hospitals had a readmission rate of 18 percent through their preferred SNF networks, a point of pride with the national average around 25-30 percent. Incorporating the Real Time platform provided transparency between both the hospitals and SNFs, dropping readmissions to 8.5 percent, a more than 50 percent decrease. This trend of declining readmissions has continued.

This 50 percent-plus drop in hospital admissions from the SNFs has been repeated now with multiple health systems.

“You can sustain the results,” Ms. Wojtusik said. Having that data, building the conversation and having those relationships leads to improved patient care because we all know it’s a bad thing for patients to be readmitted to hospitals. Readmissions happen and you’ll never get to zero, but you should get as low as you can because that’s what helps the patient.”

The results were staggering, and uniting. Both the hospital and SNF provided the best care available while maximizing benefits in both facilities.

“We could never understand and see what was really happening at the SNF, and when you’re not looking, you can’t see the things that happen that you don’t want to happen,” Ms. Wojtusik said. “[The Real Time platform] brings both sides together to focus on the right thing to do for the patient.”

To view a recording of this webinar, click here.

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