Smart SNFs: Predictive Analytics and AI

How successful SNFs are using data to predict and prevent adverse events and improve care planning

While artificial intelligence (AI) has made inroads across industries from e-commerce to marketing, in health care it is revolutionizing both the patient experience and clinical operations for care providers. And though skilled nursing is not often touted for its technology advancements, today’s successful providers are utilizing AI to predict adverse events before they take place.

The benefit is twofold for Skilled Nursing Facilities (SNFs): coordinate care and prepare for safe discharge to the community for short-stay patients and guide care plan interventions for long-stay residents.

“Accurate information about clinical course and prognosis is critical for proactive care planning,” says Nadia Angelidou, VP of Analytics at PointRight®, A Net Health Company. “For example, using predictive analytics, we identify residents at high risk for falling or pressure ulcers; we may then use this information for targeted prevention programs and early intervention. Proactive care planning at the resident level prevents adverse events, leading to better quality outcomes at the facility level.”

AI and a preventative approach to patient-level care

PointRight, which offers a comprehensive data analytics platform for skilled nursing organizations, includes in its features RADAR®, a care management tool with resident-level descriptive and predictive analytics. With RADAR®, SNFs identify which residents are at risk to experience falls, pressure ulcers, hospitalizations, mortality and returns to skilled nursing if discharged to the community. RADAR® also provides information on levels of impairment (ADL, cognition, mood, pain) and discharge complexity. Additionally, the tool shows trending views of metrics over time.

Looking at the metrics over time to understand resident dynamics, declines and improvements can be a critical differentiator for clinical operations, says Tricia Field, MBA, BSN, RN, RAC-CTA, Director of RAI Process, American Senior Communities, who with her staff has been utilizing PointRight since fall, 2018.

“It’s been an excellent resource for resident-centered care planning,” Field says. “…identifying those individuals who may be appropriate to refer to therapy based on a decline from quarter to quarter; there may be gradual changes occurring on a day-to-day basis that are not quite evident until comparing quarterly MDS-based data via RADAR.”

American Senior Communities, which operates a portfolio of skilled nursing and assisted living facilities in Indiana and Kentucky, began its PointRight training with its MDS coordinators before rolling it out to executive directors, directors of nursing and, most recently, the organization’s internal therapy team. Giving the full care team access allows all providers to gear the care plan according to each resident, with predictive analytics driving decision support for those plans.

“When we look at the RADAR® report, we can see if there has been a progressive decline or improvement in function or cognition, for example,” Field says. “This may indicate the need for modifications in clinical services or provision of additional support from other disciplines. It is an excellent tool to use during care planning to ensure that we are addressing the resident needs and risks appropriately on the care plan.”

Field’s care planning team utilizes PointRight analytics in their clinical meetings to ensure the entire team is aware of resident risks identified in RADAR. The team also references RADAR analytics with respect to discharge planning. The RADAR platform assigns a score to identify the complexity of each patient’s discharge and informs the team about the reasons driving the score.

Overall, descriptive and predictive analytics can inform providers to take an individualized approach to health care and adapt residents’ care plans accordingly.

“We identify factors that are associated with an outcome,” Angelidou says. “Predictive models give us information about residents and their risk for certain adverse events and we can identify factors that if modified, may lower a resident’s risk.”

Applying data to advanced care planning

Beyond taking action based on resident data that allows providers to prevent adverse events, SNFs also use these data to determine the opposite course is taking place and respond accordingly.

In the case of skilled nursing residents who are experiencing an ongoing decline, RADAR® allows providers to identify residents at high risk for mortality. While many residents and family members have difficulty accepting this reality, the information can help in conversations about care planning for end-of-life care and palliative care.

“Being able to identify residents who are at the final stages of their journey is critical to the planning of care management interventions,” Angelidou says. “It’s also very helpful to use data to have difficult conversations; it’s an objective way to approach a conversation that is very emotional, and talk with family members about what is best for their loved ones.”

With the ability to improve quality of life for terminally ill residents and even extend survival times, according to longstanding research published in the National Library of Medicine, these conversations and family education can be a key differentiator for some residents.

American Senior Communities has been using the mortality predictions to help in advance care planning for its residents, including those very conversations with families.

“When we see a resident who has had a continued decline despite interventions, that resident is listed as a high mortality risk in the RADAR® report,” Field says. “That tells us it’s likely time to have a conversation with the resident and/or representative to determine next steps, which may be hospice or palliative services.”

Data insights across the community — and beyond

American Senior Communities has realized additional benefits since implementing PointRight across several of its communities.

The communities’ MDS coordinators bring all MDS-based Quality Measure alerts identified by the platform to their daily team meeting to review for accuracy and determine the cause of the alerts, so appropriate action can be taken. MDS-based Quality Measure data is available at the facility level but is also visible at the regional and corporate levels which assists nurse consultants in identifying potential trends in quality of care.

Additionally, executive directors utilize the platform for PDPM insights to provide a clear dashboard on the community’s daily reimbursement rate for a given timeframe, as well as key performance indicators that can help drive areas of improvement — from physical, occupational, and speech therapy to nursing and more.

“PointRight has provided a deeper perspective to the metrics, ” Field says. “We might have known we were triggering high in certain areas, but we didn’t have easy access to the details behind the metrics without digging into each resident’s chart. It has been eye opening to have such a time-saving tool that allows us to drill down to the resident level from a single dashboard.”

To learn more about how PointRight®, a Net Health Company can help your organization use predictive analytics to improve patient outcomes and improve operations, visit

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