Smart SNFs: Optimizing Clinical Outcomes with Data

How one skilled nursing operator reduced readmissions and delivered higher quality care

In health care today, insights from data should serve as every skilled nursing facility’s differentiator and competitive edge. Yet many providers fail to apply it in a way that is sustainable and transformative for their organizations — and their residents.

The complexity of health systems creates a particular opportunity for data to help an organization optimize its outcomes and clinical care. In turn, those outcomes can lead to higher satisfaction, optimal reimbursement, and better performance in key quality areas scrutinized by the Centers for Medicare & Medicaid Services.

Such was the case for New York City-based ArchCare, the Archdiocese of New York’s health care system that every day cares for more than 9,000 seniors, the poor and persons with special needs. After a comprehensive approach to collecting, analyzing and operationalizing its skilled nursing data, ArchCare reduced rehospitalizations by double-digit percentages, improved patient and family communications, and ultimately achieved better quality of life outcomes for its residents — all of which led to value-based care success under CMS.

“Accurate assessment triggers accurate care planning,” says Mitch Marsh, ArchCare senior vice president, residential services. “It’s also helpful regulatorily.”

Developing a data-driven approach

Data has long held currency among skilled nursing facilities and for many years, ArchCare — a multi-site provider of a multitude of services including five skilled nursing facilities in New York state — has utilized PointRight, a Net Health data analytics company serving the skilled nursing industry, to facilitate its data reporting.

Prior to 2020, the organization mainly used the platform for its Minimum Data Set (MDS) assessments, scrubbing CMS data submissions, identifying outliers, and addressing any coding or reporting errors.

PointRight’s system enables users at every level of the organization — from the MDS coordinator to members of the interdisciplinary team — to ensure the MDS data is accurate even before it is submitted to CMS. Through alerts and triggers, the system flags likely coding errors so early intervention can take place. It also confirms when the MDS assessment is coded correctly so SNFs can act on the information immediately, rather than weeks or months later as is often the case with CMS data.

For ArchCare, the organization continued to improve its reporting month by month and realized efficiencies with its approach to system-wide data integrity.

“The more interaction between PointRight and our MDS director, the more we were improving until we were at more than 95% accuracy in submitting MDS data,” Marsh says. “That was just the beginning.”

With its baseline improvements and early use of PointRight, ArchCare decided to explore further ways in which a more comprehensive data-driven approach could lead to better outcomes, specifically at the patient level. Marsh and his team decided to implement several other PointRight services to address resident and population-level care management, rehospitalizations and real-time quality measures, swiftly becoming robust users of the platform.

Reducing hospitalizations with data-driven insights

Because PointRight’s database has a national reach, SNF users can compare and contrast their clinical outcomes with national averages, system averages, and community-level averages to help assess performance.

“We also look at patient cohorts,” says Janine Savage, ‎vice president, product management for PointRight. “So for patients with diabetes or heart failure, or COPD, we show outcomes based on those cohorts of patients. And that’s a really good indicator about the systems and processes of care that are in that facility.”

With both CMS and SNF providers heavily focused on hospital readmissions from skilled nursing settings, reducing readmissions was a critical area of focus for ArchCare, which initially had an average post-acute rehospitalization rate in line with the national average — between 20% and 30%.

For long-term care residents, the hospitalization rate was around 8%. Through PointRight’s predictive analytics, ArchCare was able to identify those patients likely to experience an ER transfer. Each Friday, the organization identified residents at high risk of hospitalization and developed an individualized plan for each resident based on their specific conditions and risks.

“We employed this solution to identify the people whom we needed to pay attention to and watch before the change in condition became so dramatic that it necessitated a hospital transfer,” Marsh says.

With the new approach, those transfers fell significantly. Once the program was underway at ArchCare, the transfer rate for LTC residents had fallen from 8% to 3% and rehospitalizations had fallen from more than 20% to between 10% and 12%. While the decline in rehospitalization rate carried with it many value-based care benefits, the shift also made a true impact on the quality of life among residents within the communities.

“In long-term care, the majority of the time someone declines and goes to the hospital and stabilizes and returns, it’s like going down a step,” Marsh says. “You’re stable, but not the same as before. That decline is reduced when people don’t go to the hospital. It’s a gentler slope over time.”

Easing difficult conversations and delivering better care

While ArchCare’s data-driven approach allowed it to improve among some of the metrics all providers track, there were some other tangible outcomes — particularly for an organization that regularly cares for residents and patients at the end of their lives through its long-term care offerings.

With the credibility established by PointRight’s national presence and benchmarking capabilities, many of the end-of-life conversations with family members of residents were made much more effective — which in turn led to better outcomes for all parties involved, Marsh says.

“One area that’s always difficult for families and residents is being able to identify and accept people aren’t getting better and it may be time to discuss palliative care, goals of care or advance care planning,” he says. “These are very difficult conversations.”

ArchCare was able to change the background for these conversations with PointRight’s resident-and population-level predictive analytics solution, which utilizes comparative assessments to produce a report for individuals for whom it’s time to start broaching advance care planning conversations.

“Without data, you’re just another person with an opinion, as the saying goes,” Savage says. “Whomever you are engaging in a conversation, whether it’s your referral source, the patient, or their family member, it’s important to have relevant and meaningful insights to facilitate the conversation.”

For SNFs that engage in advance care planning conversations routinely in their care delivery, these conversations can be made much more effective with validation and evidence of a resident’s decline.

“It’s very data- and clinically-driven,” Marsh says. “The reason it’s so helpful is the immediate response among families, without that lead-in, is: ‘You’ve given up.’ It’s an emotional reaction. When you lead with ‘We’ve been monitoring Mom and we employ a national analytics solution with tens of thousands of people participating,’ you generally ease people toward the conversation as to what that means.”

While many end-of-life experiences take place in acute care settings, ArchCare focused on bringing that experience home. Once the PointRight predictive analytics were at work, more than 90% of residents who passed away were in the facility with those who knew them, and with time to alert their family members, allowing them to be with their loved one in the final moments.

Improving outcomes through data analytics

In today’s operating environment, a comprehensive approach to data not only drives better outcomes, but those outcomes in turn can lead to higher quality measures as set by CMS and seen by the public at large. After implementing PointRight’s solutions, one of ArchCare’s SNFs improved its star rating from 3 stars to 5 in six months. Another improved from 1 star to 5 stars over a two-and-a-half-year period.

The approach to data can be customized to suit the needs of the organization, starting with clearly identifying those areas of need.

“The question for every user at every level is always ‘What’s in it for me?’” Savage says. “We ask: What problems are you trying to solve? What questions are you trying to answer? The general theme is always the same: It’s about better performance and fewer adverse events. Sometimes the information we provide validates what they already think. Sometimes it refutes what they think. Either way, it leads them in the right direction to take further action.”

For Marsh at ArchCare, the analytics provide “laser focus” to the care operation.

“The world we live in and the patients we serve are completely different now from when I started,” Marsh says. “The only way to effectively manage the care we need and outcomes we expect is to employ some kind of data analytics. Data analytics companies that have a national span, and tens of thousands of people feeding their database, can provide us with the kind of information we need to help make important decisions and to have critical conversations with families. It is also a great help to the staff who want to do best. This gives laser focus to whatever you have decided is important to your SNF.”

To learn more about how PointRight Analytics, a Net Health Company, can help optimize clinical outcomes in your SNF environment, visit PointRight’s solutions for SNFs.

Companies featured in this article: