Aging populations need care around the clock. Indeed, the clock is a primary tool for determining what constitutes a baseline level of care for each resident in an institutional caregiving setting.

For nursing homes such as those run by StoneGate Senior Living LLC, one key operational metric is “hours per patient day.” According to Brandon Jackson, VP of analytics at StoneGate, administrators of these communities constantly adjust staffing, assignments, and operational procedures to assure that each resident receives at least a baseline level of hours per patient day, in the form of care from nurses and other staff, to which they are  entitled or provide the best health outcomes.

Based in Lewisville, Texas, StoneGate operates 32 skilled nursing homes in Texas, Oklahoma, and Colorado. They provide 24-hour post-rehabilitative care after strokes and injuries, as well as short-term rehabilitation for knee and hip replacements. A substantial portion of residents stay in their nursing homes less than 30 days recover and return to their homes. The other population of residents live out the remainder of their lives in the skilled nursing facility. The stay of that chronic population is usually at or around two to three years.

Like all nursing home operators in the USA, StoneGate must ensure baseline care levels both to avoid legal consequences, meet care plan guidelines, and to receive the reimbursements coming to them under government incentive programs. A nursing home operator’s 5-star ranking will decline if hours per patient day declines below a specific threshold with a regulatory requirement is to maintain a minimum threshold of hours per patient day.

“The regulatory requirement is to maintain a minimum threshold of [hours per patient day],” said Jackson. “But the practical implication is if your population is very complex, you may need more oversight, even more registered nurse hours to intervene for that patient care.”

Delivering quality care within budget

StoneGate must maintain accurate record-keeping data to comply with these requirements. High-quality data-driven reports and analytics help staff to attend to the daily needs of the residents in the company’s 32 nursing homes in Texas, Oklahoma, and Colorado. These tools are also essential for the business as a whole to manage human resources, procurement, and finance operations.

Nursing labor is the key variable around which StoneGate’s operations revolve, and the essential operational factor for determining whether it consistently attains its care targets while controlling costs. “Labor is such a big part of the income statement,” stated Jackson, “that we focus there first. That helps give us visibility into our operations on a daily basis, which in turn helps us with the operational budgeting portion.”

Deploying analytics to deliver the right care at the right time

StoneGate’s ability to keep track of labor costs and other key metrics took a great leap forward slightly more than a decade ago when it invested in a high-quality data platform. That same deployment and the process innovations it enabled also gave the company’s nursing home administrators the tools for making operational adjustments more rapidly.

Early on, Jackson, who runs the data analytics operation powered by Pentaho based solutions, had to justify its relevance to business. “It’s like dial tone now: people appreciate it most when it’s unavailable.”

“Back then [in 2008],” said Jackson, “it was a lot of manual processes. So the best tools Finance and Operations had were Excel workbooks. Each functional department had separate software and workflows. Our accounting system lacked detailed information that would help us improve operations. The financial close process took 15 to 18 days because we had to wait for all other functional groups to finalize data in their separate systems.  It would take a long time to generate financial pro formas or to evaluate deals. We would know about problems too late. Once they manifest in the income statement, that meant that at a minimum those problems had gone unchecked with no response for almost 45 days, because you have the 30 day month and 15 days to close.  That put us north of 45 days to make adjustments at a management leadership level…..and that’s too late.”

What StoneGate did starting in 2009 was to invest in on-premises data integration, reporting, and business intelligence solutions from Pentaho, the solution provider now known as Hitachi Vantara. At that time, they began to consolidate siloes of clinical, operational, financial, and other data to produce higher quality data to populate operational analytics.

“It started with labor,” said Jackson, “and now our entire financial reporting is done based on data run through Pentaho Data Integration [PDI]. So we’ve made cubes and other source tables that fuel our financial reporting structure. All new deals, mergers, and acquisitions are based on PDI data transformations.  If you go over to operations, on the revenue cycle management side, we’re using Pentaho Reporting and Pentaho Data Integration to track activities of daily living and how nurse assignments are doled out.  We use PDI to aggrigate clinical quality measures, compute trends and estimate their impact on patients, staffing and financials.”

Administrators of StoneGate’s senior-living communities use this data analytics resource to build personalized care plans for each resident. “A care plan dictates that there are a certain number of tasks that have to be completed in any given day,” Jackson says, “It establishes the criterion for what counts as ‘100% cared for’.  If you complete all the tasks, the patient has received everything according to the plan.”

“The quality improvements ended up improving clinical outcomes,” he states.

Once the care plans are in place, they pave the way for staffing decisions by StoneGate’s community administrators. “If you say ‘I have a plan’, who carries it out? You have certified nurse aides, licensed vocational nurses, registered nurses, and med aides who are passing medications. All of those tasks are doled out to those individuals. If you go to another layer, you have a staffing coordinator who makes sure all care plans are assigned out by hallway and [to specific] employees on the hallway.”

The power of analytics to drive operational efficiencies comes when StoneGate analysts throw human resources data into the mix. According to Jackson, “We…scour our health records by all of the care plans, then combine that with all the employee data from the shift, who’s been assigned the tasks, and what is the current level of completion of the tasks by resident, by hall, by building.  This visibility empowers management to intervene for the benefit of patients and staff.”

Using operational data to bolster the bottom line

 These analytics are also an essential component in the revenue picture of nursing home administrators in the US. The data being gathered establishes the documentation trail needed for reimbursements by the Centers for Medicare & Medicaid Services (CMS), a federal agency within the United States Department of Health and Human Services.

“The net effect of [collecting this data] is it impacts our reimbursement,” says Jackson, “because if you have a plan and you document that you followed the plan completely, it goes pretty easily that you get paid for work done. Typically, what plagues nursing homes is that they have a plan and not all of the care plan is executed well or they provide care and do not adequately document it, and that means their Medicare and Medicaid reimbursement rate can suffer.”

“In our nursing home setting here in the US, there is one assessment called the Minimum Data Set, which is thoroughly documented by CMS. Those assessments are given on a periodic basis, and what’s implied is that the assessment records all of the activities delivered as a result of a care plan. So the work done under the care plan establishes your daily rate.  So that first assessment will be critical in establishing our reimbursement rate throughout a patient’s stay”

Under CMS’ Quality Incentive Payment Program, the reimbursements are based in part on documentation of improvements which is based upon several care outcome metrics. Key progress metrics that determine reimbursement rates include reductions in the incidence of falls, pressure ulcers, and use of anti-psychotic medications by residents.

Beyond reimbursements, StoneGate has leveraged the analytical application that it developed on the Pentaho solutions into a revenue generator. In fact, the entire deployment and operation of the Pentaho solutions is self-funded.

“The costs of the annual [software] subscription really isn’t what wags the dog,” states Jackson. “We’ve started reselling that solution to third parties, and the additional revenue generated was enough to compensate StoneGate for my salary, my team’s salary, and the development work that we did to create the dashboard and the infrastructure that it sits on in its entirety.”

Running the business on pervasive analytics

All the data and analytics that drive operational decision making permeate StoneGate everywhere from the executive suite to the nursing stations. Jackson still has to report on the program’s progress annually to senior management, but it’s primarily a nominal responsibility now. He provides management monthly with a 100-page book of metrics by region and facility, with all of that data having “roots in Pentaho Data Integration.” Both business and IT professionals in StoneGate look at its reports, with between 200-300 users on any given day.

“Hitachi clearly expresses aspirations to improve larger than life targets like smart cities and railways, but their most meaningful contribution to society has been the availability of Pentaho’s world class technology toolkit to underserved markets, communities of entrepreneurs, hobbyists, consultants, and small and medium sized businesses like ours. We are grateful for their continued commitment to good.”, said Brandon.

StoneGate runs the business on data now. The net result of implementing Pentaho for care management, budgeting, human resources, and other functions has been undeniable. A continuous pulse of data-driven analytics throughout the company has delivered better care everywhere within constraints of budget and compliance.