My mother is in long-term care.
When I show up to work every day, I’m not working from theory. I know what it feels like to trust a facility with someone you love. And after more than 30 years in healthcare—from the emergency department to community-based care to where I sit now—I also know how often the system makes that trust harder to earn than it needs to be.
The core challenges haven’t changed much, even as our technology has improved: coordination of care, collaboration among providers, and communication of what’s actually happening and when. Three things that sound straightforward until you’re managing a resident with several chronic conditions, a multitude of specialists, and a call light going off at 2 a.m. with no clinician in the building.
When Facilities Require the Most Assistance
Overnight hours often leave skilled nursing facilities most exposed. Fewer staff and limited clinical support leave staff with fewer options, which can lead to higher rates of transfers.
The residents most affected are also the most complex. The average LTC resident manages five to seven chronic conditions and sees multiple specialists, each with their own care plan. When an acute change happens overnight, on-site staff do their best, but it’s challenging.
What Telehealth Can Actually Do
“Telehealth” gets used loosely, and passive remote monitoring isn’t the same thing as delivering care. The distinction matters.
Real telehealth means a clinician on the other end of a screen who can conduct a visual assessment, respond to an acute need, adjust a care plan, and document directly into an EMR. During a major winter storm not long ago, providers couldn’t physically reach facilities, but we were there remotely. We managed acute needs, monitored residents, and avoided transfers that would have been a logistical nightmare.
The Outcomes That Earned Our Confidence
We’re careful about the claims we make. In one partnership with a multi-state SNF operator, we achieved an average rehospitalization rate of around 3%. We achieved this by treating approximately 97% of residents in the facility through our After-Hours Telehealth program, instead of transferring them out. Similarly, our Transitional Care Management program helped this operator reduce readmissions following discharges by 50% within five months across several facilities.
Those numbers reflect something we’ve come to believe deeply: continuity across settings is what determines whether the progress a resident makes in a facility actually holds. The transition home isn’t the finish line. It’s the moment that requires the most coordination and follow-through.
What Being Part of the Team Actually Looks Like
Every Lumina Care partnership begins with a clinical facility assessment. We sit down with leadership at the corporate and building levels to understand what each facility wants, needs, and can accommodate. Our clinicians have full visibility across EMRs—reviewing care plans, specialist notes, prior hospitalizations, and goals of care before interacting with any resident. We enter orders directly. Daily follow-up reports go to both the facility and the primary care provider.
Our Lumina360 dashboard gives facility leaders a real-time view of their residents—at a glance, they see action items that need attention, simplifying compliance and care management. We’re not there to replace anyone. We’re an additional set of eyes, an extension of the care team.
The Organizations That Will Lead
The organizations that thrive in skilled nursing will be the ones willing to ask hard questions about how care is delivered and then act on the answers. That’s especially true in rural areas, where a facility’s ability to offer specialty care can come down to geography as much as resources. Telehealth changes that equation without requiring a complete overhaul of staffing or operations.
My mother is in long-term care. The people caring for her are working hard and deserve every tool available to do that well. So does everyone else in care delivery.
Lumina Care, through its affiliated licensed professionals, provides virtual clinical care and operational support to skilled nursing and long-term care facilities across the country. Programs include After-Hours Telehealth, Chronic Care Management, Behavioral Health Integration, Collaborative Care Management, Telepsychiatry, Transitional Care Management, and the Lumina360 Care Analysis Dashboard.
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.
