Working on appropriate length of stay and reducing readmissions to post-acute care are keys to success for accountable care organizations. Michelle McGeachie, R.N., a certified family and geriatric nurse practitioner, is post-acute program director of the Beth Israel Lahey Health Performance Network (BILHPN) in Massachusetts. During this week’s National Association of ACOs (NAACOS) fall meeting, she described the impact of a nurse-led rounding model to improve length-of-stay management and care transitions across BILHPN’s skilled nursing facility (SNF) network.

Created in 2019, BILHPN is a clinically integrated network of physicians, clinicians, and hospitals. The network includes academic medical centers, teaching hospitals, community hospitals, and a large ambulatory and post-acute care network. For post-acute care, its broad geographic reach creates both opportunities and challenges, McGeachie said. “We're not managing patients who move from a single hospital to a handful of skilled nursing facilities; instead, we're coordinating care across multiple hospitals and a large network of SNFs spread across an expansive region. That becomes especially important in describing the SNF rounding program.”

Historically, providers across the performance network participated with CMS through four distinct MSSP ACOs with varying levels of risk. Only two of those four ACOs actually had approval for the SNF three-day rule waiver, which was confusing, McGeachie noted. 

All four of those legacy contracts ended in 2024. Beginning in 2025, MSSP participation was consolidated into two ACOs with varying levels of risk. Together, these ACOs include approximately 110,000 MSSP-covered lives, and about 270 participating TINs (Taxpayer Identification Numbers). This new structure created a more unified ACO, which is supported by centralized resources for medical management, quality improvement and reporting, risk coding, and data analytics. “The consolidation also created an important opportunity for post-acute care,” McGeachie explained. “We were able to take a more coordinated and consistent approach when building a preferred SNF network for the entire health system.”

They sought to take advantage of that centralized infrastructure to improve efficiency while maintaining quality outcomes. BILHPN wanted to reduce unnecessary days in SNFs while ensuring patients continue to receive the right care in the right place at the right time. “For us, the answer was to utilize a more uniform process to approach length of stay management and care transitions across our SNF network, while still allowing flexibility to meet the needs of the various hospitals and patients they serve,” McGeachie said. 

BILHPN includes more than 1,300 primary care providers, 13 hospitals, and serves more than 2 million unique patients annually. “These numbers are important because our post-acute care system does not operate in isolation. Our SNF program sits within a much larger ecosystem that includes primary care, specialty care, hospitals, behavioral health, ambulatory care, home health, and hospice,” she said. “Because of that, our goal wasn't just to improve the length of stay. We also needed to create a program that connected post-acute care to the broader continuum, and make the patient's journey more visible to the entire care team.”

Because BILHPN follows a clinically integrated model, they were able to create a framework that brings physicians, hospitals, and independent providers together around shared goals of quality, efficiency, and patient outcomes. “This creates the foundation for value-based care, supporting care standardization, performance improvement, and accountability across the system,” McGeachie said. “Ultimately, everyone is working toward the same objective, delivering more coordinated care, which results in better outcomes for our patients.”

Patients enter the system through the ambulatory setting. They may or may not require hospitalization, and then they transition into post-acute community-based services. To support these transitions, BILHPN has built a post-acute infrastructure that includes a SNF rounding program, the three-day SNF waiver program, its own preferred SNF network, and preferred home health providers, hospice, and palliative care partners. 

McGeachie gave a little history in terms of how the program evolved. Prior to 2020, BILHPN had a length-of-stay optimization program that was focused on reducing unnecessary days in skilled nursing facilities. Then COVID hit. As with many organizations, its existing program couldn't be sustained and was ultimately dismantled. “This required us to rethink and rebuild our approach from the ground up,” she said. When the program was relaunched in 2023, they started by looking at their claims data to understand where their patients were going for rehab. That analysis helped BILHPN rebuild the SNF network it has today, which includes 57 Tier One preferred SNFs with a CMS star rating of 3 or more. They also partner with 35 Tier Two preferred SNFs.  

Building that network was just the first step, she said. The true value of the program isn't just knowing where their patients are going, but having a process in place to influence what happens once they get there. Initially, licensed independent clinical social workers were deployed to a very small group of BILHPN’s highest-volume SNFs, with the goal of removing what they perceived to be social barriers to a safe and timely discharge. They sought to work collaboratively with the facilities to help patients return home safely and avoid utilizing unnecessary days. 

The reality was, however, that the length of stay management often came down to changes in the patient's clinical condition. “So while our social workers were very highly skilled clinicians, when facilities sought to extend a stay based on ongoing clinical concerns, a nursing perspective was really needed to evaluate the appropriateness of the delay in discharge and to set a new target discharge date,” McGeachie added. “So at that point, we realized that if we wanted to influence clinical decision-making and impact length of stay, we needed the clinical expertise of nurses to engage the SNF in those conversations.”

In the first quarter of 2025, they transitioned to a nurse-led model and redeployed their social workers to other population health initiatives where their expertise was more impactful. As they began to see modest reductions in length of stay, they were able to expand the team and extend coverage beyond the highest-volume facilities. 

Today, the program consists of eight nurse care managers who follow MSSP patients at 31 of BILHPN’s highest-volume preferred SNFs. Each nurse manager typically has a caseload of between 36 and 42 patients. The BILHPN team found that as the caseloads began to approach 50 and beyond, the nurses had less time to actively validate the discharge plans and follow up with the SNFs when the discharge dates changed to make sure that there was actually an appropriate reason for the change. 

“Their role isn't simply to track the patients; it's to have ongoing conversations with the facilities and understand why plans are changing, and help keep patients moving toward a safe discharge home,” McGeachie explained. Maintaining caseloads in that range allows them to be proactive rather than reactive. 

Another role critical to the success of the program is the post-acute engagement coordinator, who serves as the operational hub of the program. She supports stakeholder engagement, meeting coordination, EMR access for the team to the SNFs, communication across hospitals, skilled nursing facilities, home health care providers, and the ACO waiver program. 

BILHPN also convenes quarterly meetings with hospital case management leaders, representatives from their most utilized SNFs, home health agencies, and hospice partners to review the SNF network performance, address transition of care challenges. and discuss opportunities to improve outcomes. 

“The referral management platform used by our hospitals highlights our preferred SNFs that have the dedicated rounding support, so that the hospital case management teams are able to confidently discuss the value of our preferred network with patients and families,” McGeachie said. “These efforts have contributed to strong network utilization, with 11 of our 13 hospitals referring more than 80% of our MSSP patients to preferred SNFs that have rounding support.

BILPHN’s nurse-led rounding model 

Here are the core components of the SNF rounding model: Each week, the nurse care managers meet virtually with the facility interdisciplinary team and review the clinical and functional status of each of the BILPHN patients. While the discharge date remains fluid, it's important to establish an initial target date very early on, preferably at the very first meeting, as long as the patient has been evaluated by the SNF team, McGeachie said. “Having a shared goal creates alignment among the facility team, the patient, the family, and the nurse care manager.” Each week, there is a discussion about whether the patient is on track for the agreed-upon discharge date, based upon the clinical and functional updates. Any changes to the agreed-upon target date are reviewed by the SNF team and the nurse care manager together, and a new date is identified if it's needed. 

Ultimately, the purpose of the rounding is not to ask whether this patient can go home today, but to continually ask: what does this patient need to do to be get to the next level of care, and are we actively working on those things right now? 

McGeachie stressed that the nurse care managers document all of their notes in the EHR used by BILPHN, making them visible to its hospitals, primary care providers, and specialists, which helps connect the SNF stay to the patient's broader episode of care. “After a patient is discharged home from a skilled nursing facility, the nurse care manager conducts a transition-of-care call within two business days to connect with the patient and/or the family to make sure that they have everything that they need to be successful,” she added. 

“As the program matured and these processes became more consistent across the SNF network, we began to see the operational work reflected by the data,” McGeachie said. By establishing discharge goals early, identifying barriers early, and maintaining accountability throughout the stay, they created a more predictable discharge trajectory, and that allowed them to improve length of stay while maintaining a focus on quality outcomes and successful transitions back to the community. 

In 2025, the average length of stay for BILHPN’s ACO patients was 22 days. Through June of 2026, it decreased to 20.21 days, representing a reduction of nearly 1.8 days per stay. This performance puts them well below both the national MSSP average length of stay of 27.4 days and the Massachusetts MSSP average of 24.2 days. 

BILHPN also tracks outcomes separately for patients using the SNF waiver. In 2025, the average length of stay for waiver patients was 18.8 days, and in June of this year, it decreased further to 16.9 days. 

Because of BILHPN’s scale, McGeachie said, a modest change has had a significant financial effect. With just over 5,200 ACO patients going to a SNF in 2025, and an estimated cost of $651 per day, a 1.79-day reduction results in approximately $6.1 million in estimated savings. “While the financial calculation is really important, the operational impact is actually what matters the most,” she said. “An avoidable day often signals a delay in addressing a barrier to transition. So resolving those issues earlier reduces the costs and better aligns care across settings. That's what value-based care is designed to achieve. We're not trying to shorten clinically necessary stays, and that's super important for the SNFs to know. The goal is the right care in the right place for the right amount of time.”

Readmission reduction strategies

In terms of readmission reduction strategies, McGeachie explained, one of those is the documentation of the SNF stay in the hospital’s EHR. “It gives the primary care team visibility into the patient's post-acute course, which is really helpful when the patients and/or families call the office after they get home and they're having a problem.”

The transition-of-care calls by the nurse care managers help identify and address issues early after discharge, reducing the risk of unnecessary ED visits. These calls also allow BILHPN’s team to identify patients that get back home and things just aren't working out. They can help to facilitate a return to the SNF if if it's clinically appropriate. When issues such as medication discrepancies or prescription refills are identified, the nurse care managers can send a secure chat directly to the primary care provider or someone in their office to address it in a more timely fashion.

BILHPN also review readmissions and failed discharges to uncover trends, strengthen care transitions, and drive ongoing process improvement.

Lessons learned 

McGeachie said if she were to advise another ACO that wanted to build a similar program, she would share the following lessons: 

• Deploy the appropriate discipline. Not every patient and not every facility needs the same level of intervention. Match the clinical resources to the complexity of the population and the work that needs to be done.
• Experience matters. Post-acute care is a nuanced and highly regulated setting. A nurse care manager with extensive SNF experience can hear a routine update and recognize an unrealistic discharge plan or a barrier that will become a delay. Clinical judgment and knowledge of the post-acute environment make the rounds more effective and is really essential to success. 
• Be flexible with assignments. Relationships matter. A staffing assignment that works well in one facility might not work well in another. Learn to pay attention to communication styles and partnership dynamics, and to reassign when needed. 
• Invest in dedicated analytics support. You cannot manage patients you cannot identify, and you cannot improve a program that you cannot measure, she said. Timely data is needed to understand utilization, monitor facility performance, and identify new opportunities.
• Standardize the core workflow. As the program grows, informal processes can and do break down. Define how patients are identified, what is reviewed during the rounds, where it is documented, how escalations occur, and what happens after discharge. This standardization creates reliability and makes the program scalable. 
• Start with relationships and then transition to metrics. The data matters, but a facility is much more likely to engage when the ACO team is responsive, consistent, and helpful, McGeachie said. “Trust grows when we follow through, share information, respect the SNF team's expertise, and remain focused on the patient and not just the number.”