When it comes to value-based care (VBC), the Centers for Medicare & Medicaid Services (CMS) have made their intentions clear. CMS aims to align all Medicare beneficiaries with accountable care relationships by 2030 – whether through broad VBC strategies or targeted regulatory initiatives, such as the Transforming Episode Accountability Model (TEAM).
For health plans and other risk-bearing entities, this shift to VBC requires proactive, data-driven strategies to manage costs, quality and outcomes. This is especially true in post-acute care, where high costs and variability in quality and outcomes are common.
Unfortunately, many of these organizations lack clear visibility into member risk, care quality and overall network performance. This challenge often stems from fragmented, outdated data sources and manual workflows used to collect and process information. Gaining a direct line of sight into post-acute electronic health record (EHR) data can help all stakeholders in the member journey collaborate more effectively and intervene earlier in care to prevent adverse events from occurring. This, in turn, lays the groundwork for improved care coordination – and with it, better clinical and financial outcomes.
The high cost of poor care transitions
Poor transitions from hospital to post-acute care remain a persistent challenge in risk-bearing contracts. It’s no surprise that members who arrive at a facility with little more than basic discharge instructions face significantly higher risks of preventable readmissions, prolonged lengths of stay and excess utilization.
A major contributing factor is the limited and outdated data available to manage members in post-acute care. Too often, organizations rely on lagging data – such as claims records that may be several months old or Minimum Data Set (MDS) files that are delayed by up to three months.
These outdated data sets provide limited visibility into a member’s real-time medical status. As a result, it becomes difficult to manage and monitor members effectively, contributing to care gaps and increasing the risk of health deterioration. This can trigger a snowball effect – driving up care costs and reducing quality scores, both of which are critical metrics for success in VBC.
“All teams work toward positive member outcomes from both quality and functional perspectives, but achieving that is difficult without the ability to share clinical insights that enable earlier identification of changes in a member’s condition,” said Phyllis Wojtusik, RN, Executive Vice President, Value-Based Care at Real Time Medical Systems (Real Time). “Access to this data supports standardized care and promotes consistent clinical and financial outcomes. It also enables members to be treated in place, reducing the need for hospital admissions.”
Access to data drives dialogue – and improvement
Accountable care organizations (ACOs) strive to improve post-acute outcomes by enhancing care transitions, reducing readmissions and shortening average length of stay. With similar goals, health plans can look to adapt successful strategies used by ACOs to improve quality and member outcomes, strengthen care coordination and lower total cost of care.
One such example comes from New-Jersey based St. Joseph’s Health, which operates a clinically integrated network of more than 850 providers. As outlined in a case study published in 2024, St. Joseph’s embarked on a multi-year, multifaceted initiative to drive improvement. A key step in this effort was the implementation of Real Time’s interventional analytics platform. This enabled St. Joseph’s Health to gain real-time access to post-acute EHR data, evaluate members against more than 400 clinical risk indicators, alert care coordinators to changes in a member’s condition or care plan, and monitor performance metrics at both the population and network levels.
Real Time also provided skilled nursing facilities (SNFs) within St. Joseph’s Health’s network with access to analytics and insights they previously lacked. This delivered two key benefits. First, it fostered greater collaboration between the SNFs and the ACO, as all stakeholders could access the same information. Second, at the network level, it enabled increased referrals to high-performing SNFs based on live clinical and financial performance data.
A crucial tool for supporting value-based care
Implementing Real Time’s post-acute data analytics solution resulted in a measurable return on investment for St. Joseph’s Health and its ACO. Readmissions dropped from 24% to 13.6%, the average length of stay decreased by 3.2 days, and the health system achieved $1.6 million in total cost-of-care savings in just the first year of using the platform.
As noted, a key contributor to this success was the development of strong relationships with high-performing SNFs within the network. This approach is appropriate for health plans as well. By leveraging real-time insights to proactively manage care transitions and partner with top-performing post-acute providers, quality is improved through earlier interventions and reduced readmissions.
“The story of St. Joseph’s Health illustrates how aligned goals between partners can lead to improved care outcomes and lower costs,” said Wojtusik. “The ACO, like any value-based entity, is able to reduce readmissions and appropriately manage length of stay. Meanwhile, SNFs that deliver high-quality care benefit by receiving more referrals.”
Data-driven platforms like Real Time offer a scalable, EHR-agnostic solution that empowers health plans and providers with greater visibility into post-acute care. This technology enhances care coordination, reduces readmissions and total cost of care, optimizes post-acute network performance, and supports effective resource management. For health plans and risk-bearing entities, Real Time is more than a data platform – it delivers actionable insights and serves as a strategic partner in achieving the highest quality of care and best possible member outcomes.
The editorial staff had no role in this post's creation.