The Last Mile of Care: Why Value-Based Success Starts at the Bedside

If your value-based care strategy doesn’t reach the bedside, can it really be called care?

We’ve seen growing investment in population health platforms, analytics dashboards, and retrospective reporting tools. But far too often, those efforts stop short of impacting what truly matters — what happens in the moment, at the point of care. I call the final link between strategy and execution – where real-time care decisions are made and outcomes take shape–the last mile of care. In value-based capitated models, this is the point where success or failure is ultimately decided.

Analytics without action 

Many solutions today are built to aggregate and analyze, not to intervene. Practice groups and ACOs are handed dashboards often filled with outdated retrospective data, but their frontline clinicians are left fishing in the dark. They may know which patients are high risk in theory — but not in the moment it matters most, where they have a potential opportunity to intervene and change the course of a poor outcome.

Often, clinicians don’t have visibility into whether the patient in bed 14 is part of an ACO, an I-SNP, or traditional Medicare. Each of those programs comes with its own model of care, documentation and coding requirements, clinical pathways, and quality measures. And without that visibility at the bedside, precision care becomes guesswork. If we can’t support care teams at the point of delivery, we won’t move the needle on outcomes — or reimbursement.

What the last mile actually looks like

I’ve spent a lot of time with post-acute and long-term care physicians and advance practice clinicians in the field and their daily routine is intense: seeing 20+ patients across multiple skilled nursing facilities, often with limited support staff, and constant coordination with overstretched nursing teams. The work is relentless — and the stakes are high. Every decision, every piece of documentation, every missed warning sign can ripple downstream consequences.

At the bedside, practitioners are not just providing care. They’re reconciling medications, identifying signs of decline, aligning with facility care plans, and capturing clinical documentation that drives reimbursement in models like PDPM, for ACOs, and Medicare Advantage plans, such as I-SNPs. And often, they’re doing all of this without a clear view into the patient’s full clinical context or risk model. It’s no wonder so much value is left on the table.

This is where technology must do more than provide reporting. It must enable action. Practitioners need tools that surface critical, contextual information — meaningful changes in condition, behavioral health, longitudinal information from recent hospitalizations, and early warning flags for infections — at the right time and place where treatment decisions are being made. That’s not analytics. That’s enablement.

Why integration is non-negotiable

Care collaboration doesn’t work without shared workflows. It’s not enough to read data — your entire interdisciplinary team has to be able to act on it. If your system doesn’t allow for entering orders, syncing diagnoses, or offloading work from nursing teams, you’re not enabling care, you’re simply documenting an encounter note.

True integration means:

• Timely attribution: Knowing immediately which plan or payer model a member is enrolled in, or a patient is attributed to
• Unified patient context: Diagnoses, medications, behavioral alerts, changes in condition and more — all in one place
• Bi-directional collaboration: Orders and updates flow seamlessly between practice groups and Skilled Nursing and Senior Living Facilities

Groups that show up with disjointed tools or scanned PDFs are increasingly seen as lagging in their partnership. Facilities want partners who can plug into their workflows and deliver results. They need more — and they deserve better.

What success looks like

Some organizations are already showing what success looks like when infrastructure enables holistic care delivery. When groups can benchmark key metrics like avoidable hospitalizations, ED transfers, documentation completeness, and facility-level performance — and use that data to guide interventions — they can demonstrate real return on investment.

In my own conversations with SNF leaders, I’ve heard this again and again: “We’d switch groups if they could give us material improvement in our clinical outcomes and share the same information highway, which is so critical to reducing the burden on our constrained nursing staff.” That’s what the industry is demanding — not more dashboards, but bedside-aware, data-driven systems that improve both care and performance.

What leaders should be asking

If you’re a practice group or facility leader evaluating your value-based care strategy, start with these questions:

• Can your clinicians see patient attribution and risk information in the moment?
• Are diagnoses and documentation synced between facilities and risk-bearing entities?
• Do your workflows enable timely interventions at the bedside?
• Can you benchmark your performance through metrics like hospitalizations, ER utilization, and risk adjustment?

If the answer is no, you’re not solving for value — you’re driving while looking in the rear view.

It all comes down to the bedside

The last mile of care isn’t where the work ends — it’s where value begins. The most advanced analytics mean nothing if they can’t be activated by the people delivering care.

If we want to succeed in value-based care, we have to move from systems that observe from a distance and start equipping frontline clinicians with the tools and support they need. That’s where real, informed, holistic care takes place — and where the future of healthcare will be achieved.  

Photo: SDI Productions, Getty Images

Dr. Steve Buslovich is Chief Medical Officer, Senior Care for PointClickCare. He is a geriatrician and certified medical director of several nursing homes and post-acute care facilities located in Western New York. Dr. Buslovich is an active committee member of the American Geriatrics Society (AGS), Advancing Excellence in Long Term Care Collaborative, and the Society for PALTC Medicine, where he serves on the Public Policy and Clinical Practice Guidelines Committee. is currently collaborating with CMS and ONC to establish standardized clinical data elements across all post-acute care settings.

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