How to achieve post-acute interoperability, obtain accurate patient data in real-time, and deliver quality care

The COVID-19 pandemic has further exposed the detrimental results inefficiencies can have on skilled nursing facilities. 

During an Aug. 20 webinar hosted by Becker's Hospital Review and sponsored by Real Time Medical Systems, Phyllis Wojtusik, RN, executive vice president of health system solutions at Real Time Medical Systems, discussed how to access real-time data from post-acute partners to drive clinical and operational workflow, deliver quality care and reduce hospital readmissions.

Lack of seamless data exchange can diminish patient care, leading to poor health outcomes and higher costs. There is no unified electronic health record system across all healthcare organizations, and 66 percent of post-acute providers still share and access patient data with referring hospitals via fax machines.

One of the riskiest times for misinformation to be introduced is when a hospital patient is discharged and placed into another care setting, such as a skilled nursing facility. In 2019, 83 percent of the 3,129 hospitals in Medicare's Hospital Readmission Reduction Program were penalized for excess readmissions. To mitigate risk and reduce readmissions, it is critical health systems obtain correct patient information in real time.

Five strategies to obtain accurate patient data and drive the best clinical outcomes:

1. A health system case management infrastructure should include: 

  • Early intervention to prevent downward spiral and readmission
  • Appropriate transitions of care both in and out of the skilled nursing facility 
  • Monitoring adoption of clinical standards of care
  • Connecting patients back into primary care provider network and ambulatory case management
  • Access to live clinical data
  • Alerting system to identify potential clinical issues 
  • Risk stratification of the population
  • Help identifying root cause analysis when readmissions occur

2. A plan of care must be developed collaboratively to drive care process improvements within a SNF network, Ms. Wojtusik explained. Upon admission to a- SNF, an estimated discharge date should be determined and a care team should hold an onboarding meeting with the patient and family to set expectations. This helps invest and engage patients in their own care, Ms. Wojtusik explained. Clinical data should be used to monitor length of stay, and any gaps on both acute and post-acute sides should be identified. Furthermore, a solid discharge process should be embedded within the SNF, including a follow-up with a primary care provider, a follow-up phone call from the SNF within 72 hours and connection to community services before leaving the facility. 

3. Clinical performance should be driven by transparent data, Ms. Wojtusik said. To achieve daily clinical care goals, interval outcomes and progression toward discharge should be monitored; an educational plan should be established across the continuum of care; and assessment guidelines must be maintained.

4. To successfully manage SNF patients remotely, organizations should focus their resources on high- or rising- risk patients, Ms. Wojtusik said. Risk should be evaluated based on the recency of admission, changing clinical picture, history of readmissions and comorbid diagnoses. After identifying high-risk patients and what specifically puts each one at risk, organizations should mitigate risks through early symptom identification. Organizations should monitor subtle clinical changes, such as comorbid conditions, weight changes, fluid intake, bowel management, pain intensity and management, vital sign changes and infection risk.

5. To control costs and reduce length of stay, a four-hospital regional health system in the eastern U.S. implemented Real Time Medical Systems' platform in 2016. The system managed a network of 10 skilled nursing facilities and discharged 3,000 to 4,000 patients per year to the facilities. The organization used the platform to access live data from the post-acute EHR 24/7, monitor patient care post-discharge, immediately identify at-risk patients, collaborate with post-acute clinical teams and deploy clinical standards. Within a year, the organization saw a 42 percent reduction in length of stay, a 57 percent drop in readmission rates, and saved more than $4 million.

For more information about Real Time Medical Systems, click here. To view the full webinar, click here. 

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