For skilled nursing facilities
Keep Your Residents Here. Keep Your Revenue Here.
A physician-designed program that helps your team see which residents are at risk of going back to the hospital, days before a 2 a.m. transfer. It uses the PointClickCare records you already keep.
No cost, no obligation. Your clinicians keep every care decision.
01What's changing
Medicare Will Soon Pay You Based on the Readmissions Your Team Could Have Prevented
A new measure counts potentially preventable readmissions that happen during the resident's stay with you. It replaces the old 30-day readmission measure in the SNF Value-Based Purchasing program.
Oct 2024 – Sep 2026
Your first score
Payments change
Oct 1, 2027
Already scored. These months are over and can't be changed.
Still yours to shape. Every admission from today on counts toward the scores that follow.
What the new rule means for you
- A transfer during the stay that could have been prevented now counts against your score.
- Your score decides how much of the 2% Medicare withhold comes back to your building.
- The first score is built from months that are already over.
What Keystone puts in place
- Every new admission scored for risk before 8 a.m.
- Your DON confirms each score by 10 a.m.
- Protocol tasks show up in PCC the same day, so your team acts early.
- Monthly results reports show where you stand.
The hospital and the facility no longer share the blame. Every readmission counted is a resident your building could have kept.
02The cost
One Avoidable Readmission Costs Your Building in Three Ways
It isn't one bill. It's three, and they arrive at different times.
Lost Revenue
About 20 Medicare days leave with the resident, at about $600 a day.
~$12K
Payments at Stake
Medicare holds back 2% of Part A payments. Only 60% is paid back, based on each facility's score.
2%
Hospital Referrals
Readmissions drop 6.1 points when hospitals use a preferred SNF network, versus 1.6 when they don't. Hospitals notice who sends patients back.
6.1 vs 1.6
Sources: CMS SNF Value-Based Purchasing Program; Health Affairs, Sept 2017. The $12K figure is an illustration.
03The program
Three Phases, and the First One Is Free
Everything is remote. No site visits to schedule, and no new software for your nurses or CNAs.
-
Phase 0Free · 2 weeks
Transfer Review
We review your last 90 days of hospital transfers and report the facts: when they happened, the warning signs in the chart beforehand, and what they cost.
Your partSign a BAA and give Keystone PCC access.
-
Phase 16 weeks
Setup
We put the tools in place and train your staff.
- Admission risk screen
- PointClickCare care plan templates
- Goals-of-care and medication checks
- Change-in-condition and after-hours plans
- Staff training
Your partShort training sessions for your team.
-
Phase 2Monthly
Ongoing Support
Your leaders see risk every day, and you see results every month.
- Daily watch list for your leaders
- Weekly huddle report
- Transfer report, facts only
- Monthly results for you and corporate
Your partYour DON confirms a short list each morning.
Start with the free review. Decide on the rest only after you've seen your own numbers.
04A weekday with Keystone
Risk Is Caught in the Morning, Not at 2 a.m.
Keystone does the screening. Your team makes the calls.
Without a daily screen
2:00 a.m.
The warning signs were in the chart for days. The first alarm is a night call, and the resident leaves by ambulance.
With Keystone
8:00 a.m.
The same signs are flagged before the morning meeting. Your team has the whole day to act, with the family and the provider.
Before 8 a.m.
New Admissions Are Scored
Fifteen chart facts, from recent hospital stays to medication mismatches, add up to a High, Moderate or Low score.
By 10 a.m.
Your DON Confirms the List
Leaders get a short list in Microsoft Teams or the system your facility already uses.
All day
Tasks Appear in PCC
They show up on the eTAR and Point of Care screens your nurses and CNAs already use.
Early
Your Team Acts in Time
Your clinicians decide whether to treat in place or plan ahead with the family.
112R.T.
Heart failure; 2 hospital stays in 6 months; admitted on a Friday evening
High · 10204M.J.
Medication list doesn't match hospital discharge; on insulin
High · 8131A.W.
COPD; goals of care not yet documented
Moderate · 5Scored from chart facts before 8 a.m. · Confirmed by your DON
- No new software for nurses or CNAs
- Your clinicians make every care decision
- Finished tasks are closed from your PCC records
05The evidence
Programs Like This Work When the Team Stays Engaged
Published studies show the same pattern: early warning, used every day, keeps residents in the building.
24%
Fewer Hospital Admissions
In nursing homes that actively used INTERACT II, versus 6% in those that didn't.
6.8 pts
Lower 30-Day Readmissions
Cleveland Clinic program in 7 SNFs, with frequent physician visits.
~30%
Lower Odds of Readmission
Enhanced Care Program across 8 SNFs, with staff education.
Our target for your building
15–25% fewer readmissions
Keystone keeps your team engaged every day, which is what the studies above depended on.
Sources: Ouslander et al., J Am Geriatr Soc 2011; J Hosp Med 2017 (Connected Care) and 2018 (Enhanced Care Program). Results vary by facility; the target is a goal, not a guarantee.
06Built for trust
The Three Questions Every Administrator Asks
Clear roles, protected data and simple fees, answered before you have to ask.
“Who makes the care decisions?”
Your Clinicians. Always.
Keystone provides protocol templates, staff training, daily risk flags and results reports: facts and scores only. Your medical director, physicians and NPs make every care decision.
“Is our residents' data safe?”
HIPAA From Day One.
A business associate agreement is signed before we see any record, even for the free review. Resident information stays in HIPAA-covered tools. Watch lists show room numbers and initials only.
“What will it cost us?”
A Fixed Fee, in Writing.
A fixed monthly fee, set in writing, never tied to admissions or referrals. Start with a 90-day pilot and targets we agree on together.
07Why Keystone
A Doctor Who Has Worked Every Side of the Transfer
He knows which transfers didn't need to happen.
5
SNFs led as medical director
2016
SNF physician since
3
Sides of the transfer
Now
- Practicing hospitalist
- Hospice medical director
Before
- Medical director, 5 SNFs
- Hospitalist medical director
- P&T committee chair
Founder and consultant. Your clinicians keep every care decision.
Dr. David BudhooFounder · Upstate South Carolina
08Your next step
Your Next Avoidable Transfer Could Be This Weekend.
Find it before it finds you. Request a free 90-day transfer review.
350
days until Medicare payments changeOct 1, 2027 · and today’s transfers count toward the scores after that
- $0Free review
- 0Obligations
- 0New software
- BAASigned first
- 1You call
- 2We sign a BAA
- 3Your review in 2 weeks
Two weeks from your call, you'll know which transfers could have been prevented, and what they cost you.
Keystone Transitions GroupReadmission prevention for skilled nursing facilities