Nurse-led SNF program cuts stays by nearly two days

A nurse-led rounding program at the Beth Israel Lahey Health Performance Network (BILHPN) has reduced average skilled nursing facility (SNF) stays by nearly two days since 2025, while maintaining low readmission rates. The initiative now operates across 31 high-volume SNFs, employing eight nurse care managers who collaborate directly with facility teams to establish discharge goals and address obstacles. This effort has decreased average stays from 22 days in 2025 to 20.21 days by mid-2026.

The program’s effectiveness stems from shifting from social worker-led interventions to clinical oversight. Before 2025, BILHPN relied on social workers to handle social discharge barriers, but found that unresolved medical issues—often requiring nursing expertise—prolonged stays. The nurse-led approach now centers on weekly virtual meetings with SNF interdisciplinary teams, where care managers review patient progress and adjust discharge timelines collaboratively.

Unified ACO structure enables SNF coordination

BILHPN’s strategy builds on its consolidation of accountable care organization (ACO) structures. The network, comprising 13 hospitals and 1,300 primary care providers, transitioned in 2025 from four separate Medicare Shared Savings Program (MSSP) ACOs to two unified entities. This change enabled a more coordinated SNF network, including 57 Tier One facilities with CMS star ratings of 3 or higher and 35 Tier Two partners.

A key feature is the early setting of discharge targets, typically within the first week of admission, with weekly progress checks. This transparency aligns expectations among patients, families, and care teams. All interactions are documented in the electronic health record (EHR), ensuring visibility across BILHPN’s continuum of care, from hospitals to primary care.

Beyond reducing stay lengths, the model improves care transitions. Nurse care managers conduct follow-up calls within two days of discharge to address issues such as medication gaps or home safety concerns. These interventions help lower avoidable readmissions by catching problems early, often before they escalate into emergency department visits.

Cost savings and waiver patient benefits

For waiver patients, those eligible for the SNF three-day rule exemption, the average stay dropped from 18.8 days in 2025 to 16.9 days by June 2026. With over 5,200 ACO patients in SNFs last year and daily costs averaging $651, even a modest reduction yields significant savings. BILHPN estimates the 1.79-day decrease saved roughly $6.1 million in 2025 alone.

The program’s scalability depends on careful caseload management. Each nurse care manager oversees 36 to 42 patients, a balance that allows for proactive engagement without overwhelming response times. Caseloads exceeding 50 patients, the team found, weakened their ability to validate discharge plans and address changes in real time.

A supporting role is filled by the post-acute engagement coordinator, who handles logistics such as EMR access, stakeholder meetings, and cross-team communication. Quarterly meetings with hospital case managers, SNF leaders, and home health partners further refine the network’s performance.

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BILHPN’s data demonstrates the strategy’s effectiveness at scale. While the national MSSP average SNF stay is 27.4 days and Massachusetts’ average is 24.2, the network’s 20.21-day average falls below both benchmarks. The financial impact is clear, but the operational benefit, resolving transition barriers earlier, reduces costs and aligns care across settings.

Broader care continuum integration boosts outcomes

Next steps include expanding to additional facilities and refining analytics to identify high-risk patients before discharge. The nurse-led rounding model’s broader impact extends beyond individual facility performance, embedding itself into BILHPN’s wider care continuum. The network’s clinically integrated structure, spanning 13 hospitals, 1,300 primary care providers, and over 2 million annual patients, requires seamless coordination across settings. Post-acute care does not operate in isolation; it intersects with ambulatory services, specialty care, and behavioral health.

The rounding program’s integration into this ecosystem ensures visibility of a patient’s journey from admission through discharge and into community-based care. By documenting SNF stays in the shared EHR, primary care teams gain insights into a patient’s post-acute experience, proving critical when families report issues after returning home. This real-time data flow helps providers anticipate and address gaps before they escalate into readmissions or emergency department visits.

The program’s design reflects BILHPN’s transition from a fragmented Medicare Shared Savings Program (MSSP) structure to a unified accountable care organization. Before 2025, the network operated under four separate ACO contracts, two of which held approval for the SNF three-day rule waiver, a discrepancy that created confusion. Consolidation into two unified ACOs in 2025 eliminated these inconsistencies, allowing BILHPN to standardize its preferred SNF network.

The new structure, serving approximately 110,000 MSSP-covered lives, centralized resources for medical management, quality improvement, and data analytics. This alignment was essential for scaling the rounding model, providing a consistent framework for length-of-stay management across 57 Tier One and 35 Tier Two preferred facilities. The unified approach also streamlined the waiver program, ensuring all eligible patients could access coordinated care without bureaucratic hurdles.

Historically, the rounding program faced disruption during the COVID-19 pandemic, when BILHPN’s original length-of-stay optimization efforts were paused. The 2023 relaunch began with a data-driven rebuild, using claims analysis to identify high-volume SNFs and refine the preferred network. Initially, licensed independent clinical social workers targeted social barriers to discharge in select facilities, but the team quickly recognized that clinical, not just social, factors drove most delays.

By early 2025, BILHPN transitioned to a nurse-led model, redeploying social workers to other population health initiatives. The shift proved effective: nurse care managers, with their specialized knowledge of SNF operations, could evaluate the appropriateness of extended stays and collaborate with facilities to set realistic discharge targets. This clinical oversight became the foundation of the program’s success, reducing average stays while maintaining quality.