An improved relationship between health systems and skilled nursing operators lies in improving clinical pathways – providing a game plan for residents transitioning from one part of the care continuum to another to avoid poor patient outcomes.
Live data is key to improving performance across the continuum and coming up with the right pathway for each resident, according to Dr. Steven Stein, chief medical officer of Real Time Medical Systems. More traditional modes of monitoring like claims and electronic medical records (EMRs) give outdated feedback, he said.
Stein spoke about post-acute care at a RISE Association webinar earlier this month; RISE is a provider-based organization to educate health care workers on value-based care and government health care reform.
Stein was previously chief medical officer for Trinity Health and has served on the White House Council on Aging for the Clinton and Obama administrations.
Almost half of provider listeners during the webinar said they don’t monitor clinical pathways between hospitals and SNFs, while others said they assess pathways via electronic health records or phone and email contact.
In a later poll question, 57% of listeners said they measure the success of a nursing home based on claims, followed by 29% that go by facility self-reporting; 14% look at the minimum data set (MDS) and zero use EMRs.
“Optimal communication across different disciplines is even harder to do because of the staffing shortage,” noted Stein. “A staffing shortage in nursing homes makes it that much more difficult to work through what is generally a pretty fragmented nursing home EMR.”
Live data, as defined by Real Time, is considered data entered into the EMR as it’s happening, in “real time,” compared to static data entered for a specific time period. That includes nurse notes, and the potential to identify subtle changes to residents via interventional analytics.
One listener considered their relationship with SNFs “rocky,” and expressed skepticism that a facility may not be willing or want to share their live data with health systems. Stein said nursing homes in general are looking to become more efficient right now because of staffing challenges.
“If you bring a tool to [nursing home operators] that would allow them to have better insights to situations that they need to attend to, or information that gives them a sense of trends and where their biggest opportunities for improvement are – those type of things allow more people to be at the bedside,” explained Stein. “They’re not seeking information in sometimes fragmented electronic medical systems.”
An accountable care organization (ACO) helps maintain regular communication between hospitals and nursing homes too, Stein said, avoiding the pitfalls of misinformed pathways decided by outdated information.
“The MDS is often not completed. It doesn’t have to get to CMS until 15 days into the stay. You can imagine a lot of the readmissions have already occurred by day 15,” added Stein. “Two-thirds of those 30-day readmissions occur in those first 14-15 days of the nursing home stay. Waiting for the MDS to be completed to the CMS and that using that information is probably not going to be as helpful as real time, live data.”
ACOs keep clinical pathways “front and center” for nursing homes and the physicians who work there, Stein said during the webinar.
Understanding the staffing makeup of area nursing homes is crucial to better clinical pathways too, according to Stein, again referencing staffing shortages in the industry. Facilities have a “wide variability” in clinical staff count and hours, Stein said, and physicians need to establish a clinical pathway that works well with established nursing home workflow.
“You can define your expectations on how they would handle heart failure, diabetes, how they would handle things like length of stay,” said Stein. Once expectations are set between a health system and SNF, live data allows “true visibility” into how care is being delivered in a facility.
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