Visibility Is Essential to Quality Care Delivery
Escalations in care happen. As Dr. Elena Vezza, CMO of Lumina Care’s After-Hours Telehealth Program, said in a recent interview, “You can’t prevent every hospitalization. Some residents have to go.”
The choice to hospitalize, however widespread in practice, correlates more often with several compounding factors, and rarely a single moment of catastrophic change.
More often than not, it’s a lack of visibility and access leading up to a crucial moment. A nurse on the floor at 10:30 PM can’t reach a clinician to treat a patient in crisis. But what happened in the days or hours before?
Visibility across clinical partners, specialities, and care platforms (EMRs) can limit the impact of these moments.
The Data Is Clear
Hospitalizations in long-term care are a layered problem where complexities converge.
On average, SNFs experience a readmission rate of around 20%, according to 2023 data. We know from data collected with partners of Lumina Care that this rate can be significantly reduced by introducing after-hours telehealth.
For a wider context, in SNFs, behavioral health (BH) diagnoses have increased 80% in the last 15 years (Public Policy & Aging Report).
The readmission rate for patients with BH diagnoses is 77% higher than that of patients without. This is elevated for those with comorbidities (Center for Health Information and Analysis).
This paints a very clear picture of the risk of readmissions in the SNF setting, but it does not mean the status quo is acceptable.
Lumina Care has reduced readmissions to around 2% on average across 50,000 SNF residents. In the transitional care setting, that is further reduced to 1%, on average.
Coordination and Visibility
How do we begin to solve these three big issues of readmissions, access, and operational burden?
Collaborative care models (CoCM) have shown their efficacy, reducing net care costs through team-based interventions by hundreds of dollars per patient per year (AIMS).
CoCM reduces costs:
$952 — Net economic benefit of the intervention is $952 per patient treated (AIMS Center, 2025)
We also know from real-world data collected with Lumina Care providers that the implementation of After-Hours Telehealth (AHTH), Chronic Care Management (CCM), Transitional Care Management (TCM), and Behavioral Health Integration (BHI) reduces burdens on staff, improves care outcomes, and supports clinical and administrative staff.
The key to the success across these programs shares essential elements:
- EMR integrations that ensure up-to-date patient information is shared with clinicians.
- Patient-centered care delivered in collaboration with facilities that fit within their existing frameworks.
Limiting escalations and hospitalizations begins at care planning, where prevention starts with visibility: care data that is accessible, shared between specialists, and easy to access at a moment’s notice.
This extends to programs like AHTH, where readmissions can be avoided one by one, by having clinical expertise available in minutes instead of hours or days.
Results Found with Better Visibility
Three of Lumina Care’s clinical experts spoke at the BHB Value Conference in March. Their panel focused on the outcomes of shifting long-term care delivery from reactive to proactive.
While their panel focused on behavioral health, it also underscored the importance of visibility in delivering high-quality, patient-centered care across care settings.
Even for complex care management like behavioral health, visibility and access play a major role in improving outcomes.
Polypharmacy remains a focus of improving care delivery, and gradual dose reductions (GDRs) are a goal for CMS as well as conscious care providers like Lumina Care.
For example, tools like Lumina360 provide insights into justified antipsychotic use and make it easier for providers to:
- Track behavioral changes
- Monitor polypharmacy and use of antipsychotics
- Track gradual dose reductions (GDRs)
- Monitor hospitalizations
Here’s a real, anonymized example:
Your Responsibility: Be More Proactive
As discussed by Dr. Glen Rebman and Dr. Laura Geiger at the Behavioral Health Business conference this year, rethinking the approach to care delivery requires a shift from reactive to proactive.
Especially in complex care settings where chronic comorbidities coexist with behavioral health needs, visibility should be considered an essential component across care teams—clinical, operational, and leadership.
As outlined here, care management programs that are proactive prioritize visibility, coordination, and collaboration. The outcomes are two-fold: lower net costs and higher care quality.
For those in long-term care and post-acute care, the priority should always be the same: maintain comfort and quality of life for residents and minimize disruptions, the most dangerous of which are hospitalizations.
Lumina Care delivers continuous, coordinated care by connecting providers nationwide. At all hours and across settings, we integrate directly with your team to reduce complications, improve outcomes, and support around-the-clock clinical care without adding to your workload.