The key to reducing hospital readmissions from SNFs by 50%? A program built around Real Time SNF data

Hospitals and health systems today are pressed to improve patient outcomes while reducing costs. To overcome this two-pronged challenge, many provider organizations are focusing their efforts on reducing readmissions.

As the healthcare industry shifts from fee-for-service medicine, reimbursement is becoming more closely tied to value-based care. This transition makes it more important than ever for hospitals to work closely with post-acute care providers to improve patient outcomes and reduce readmissions.

During the Becker’s Hospital Review Health IT + Clinical Leadership + Pharmacy conference in Chicago this May, Real Time Medical Systems Founder and Executive Chairman Scott Rifkin, MD, discussed some of the common obstacles hospitals face in managing care for patients discharged to a skilled-nursing facility and how access to real-time data can help care teams overcome these challenges.

Challenges of managing an SNF network

A hospital’s readmission rate is an indicator of care quality and the effectiveness of its discharge planning. However, many hospitals struggle to limit readmissions from SNFs.

One of the biggest challenges hospitals face in cutting their readmission rates is a lack of real-time, actionable data from SNFs, Dr. Rifkin told healthcare executives at the Becker’s conference.

“Hospitals aren’t able to get good data from nursing homes,” he said. “And the data you do get is MDS data. It’s a year old when you get it.”

Basing clinical decisions on old MDS data keeps hospitals in a reactionary state and prevents them from addressing key interventional moments in a patient’s care. Dr. Rifkin also noted that year-old trend data has limited value because the average nursing home staff turnover rate is roughly 67 percent a year.

Instead of dated MDS data, some hospitals rely on more timely self-proclaimed information from a nursing home. However, Dr. Rifkin said the data nursing homes provide is unreliable because it can be manipulated before it is shared.

Hospitals need access to the same information and alerts the nursing homes have to better manage patients discharged to SNFs. To gain this insight, many hospitals are using Real Time Medical System’s interventional analytics platform. Hospitals that have real-time access to nursing home clinical data have proven to reduce readmissions by 50 percent or more.

Using real-time data to reduce readmissions

Real Time’s software links directly to the SNF’s EHR, giving hospitals access to real-time health record data after a patient is discharged to a nursing home. Collecting and analyzing patient data in real time helps hospitals reduce readmissions and drive down costs.

During the Becker’s conference, Phyllis Wojtusik, RN, executive vice president of Real Time Medical Systems and former director of post-acute care at Lancaster (Pa.) General Health, discussed how the Real Time platform helped Lancaster General avoid costly readmissions.

First of all, the software is easy to install and use because there’s no IT integration with the hospital system’s EHR, said Ms. Wojtusik. The platform extracts data from the SNF’s EHR, enabling hospital case managers to collect and analyze patient data in real time. The system identifies high-risk patients in the SNF, feeds the alerts leading to that conclusion to the case managers, and allows for immediate intervention before hospitalization.

“Data comes directly from the SNF’s EHR. They just document once and we pull it all out,” Ms. Wotjusik said. “It’s cloud-based, HIPAA secure and you see the same data your SNF does.”

Lancaster General saw a decrease in readmissions after launching the platform and sustained those results. The hospital, part of Philadelphia-based Penn Medicine, had a readmissions rate of 18 percent in fiscal year 2016. That number dropped to 8.5 percent in fiscal 2017, the first year it used Real Time’s platform. The hospital’s readmission rate declined to 8.2 percent in fiscal year 2018. For hospitals that are part of an ACO, the avoidance of unnecessary readmissions is especially paramount. Ms. Wojtusik said the Real Time platform helped Lancaster General’s ACO improve on several key metrics.

“Under our ACO, we dropped SNF utilization by 43 percent in that first year. That was $4 million dollars in savings to our ACO,” she said. “We took the cost curve that was going up and brought it almost directly down.”


Reducing readmissions is a top-of-mind concern for hospital executives across the nation. With access to real-time data, hospitals can effectively manage their post-acute SNF networks, cut readmission rates and drive down costs. To gain access to the same data SNFs have in real time, many hospitals are turning to Real Time Medical System’s platform and improving their clinical and financial performance as a result.

About Real Time Medical Systems

Real Time Medical Systems is the leading healthcare interventional analytics company helping to improve the patient care continuum by connecting long-term care facilities, hospitals, ACOs, payers, and affiliated providers in building an integrated preferred care network.

Empowering a proactive approach to patient centered care, Real Time’s interventional analytics platform was developed for skilled nursing facilities to easily identify patients who had a change in care condition and intervene immediately before re-hospitalization occurred – helping to improve clinical and financial performance while reducing readmission rates by 50%. Since launching their interventional analytics platform in 2012, Real Time has expanded their solution offering to include fully-integrated applications which allow hospitals, ACOs, payers, and affiliated providers to connect and collaborate with their post-acute care networks.

Operating in 700+ facilities, throughout 30+ states, and monitoring nearly 100,000 lives – Real Time continues to ensure patient-centered care is at the forefront for its clients.

For more information or to request a demo of the Real Time ProACT HS application, contact Tommy Pfeiffer, Director of Health System Solutions at [email protected]