Optimizing Post-Acute Transitions and Length of Stay in Skilled Nursing Facilities
October 03, 2025 | Categories: ODG by MCG
As healthcare continues to transform, shifting away from fee-for-service and moving toward value-based care, optimizing post-acute transitions has become paramount. Ensuring patients transition seamlessly through the care continuum not only improves outcomes but also reduces unnecessary costs. Skilled nursing facilities (SNFs) are at the center of this transformation, tasked with managing increasingly complex patient populations while meeting rigorous quality and efficiency standards.
The Challenges of Managing Length of Stay in SNFs
Prolonged stays in SNFs create cascading challenges across the healthcare system, such as a higher likelihood of hospital readmissions, increased healthcare costs, and greater risks of complications that can hinder patient recovery. The complexity of SNF patients, who often have multiple chronic conditions and functional dependencies, makes it difficult to apply length of stay (LOS) targets.1 Inefficient discharge planning,2 compounded by varying definitions of the ideal LOS, further complicate timely and cost-effective transitions.3
Other significant barriers include inconsistent communication between hospitals, SNFs, and home health providers, which can result in delayed discharges or readmissions. Regulatory and reimbursement pressures, such as those introduced by the Patient Driven Payment Model (PDPM), incentivize shorter stays but can inadvertently risk under-provision of care if not carefully managed.4,5 Additionally, workforce shortages and social determinants of health (SDoH), such as lack of caregiver support or safe housing, can delay safe discharge and disproportionately impact vulnerable populations.6,7
Parrish Healthcare’s Integrated Approach to Post-Acute Care
Parrish Healthcare, in collaboration with MCG, has pioneered a patient-centered, integrated care model certified by The Joint Commission that is designed to ensure coordinated, seamless transitions at every stage of recovery. Their model incorporates:
- An Integrated SNFist Program: A team-based approach involving hospitalists, medical group SNFists, utilization review navigators, and transitional care teams
- Enhanced Communication: Coordination across hospitals, SNFs, primary care providers, and home health services, ensuring a unified plan for each patient
- Person-Centered Care: Care plans that prioritize individual needs, supporting patients throughout their recovery journey
This integrated approach has demonstrated that evidence-based care pathways, when combined with strong communication and coordination, can significantly improve patient outcomes and operational efficiency.
The Role of MCG Care Guidelines
At the heart of Parrish Healthcare’s transformation are MCG Recovery Facility Care guidelines, which provide actionable insights and standardized pathways for common SNF diagnoses. These guidelines support clinicians in making consistent, timely decisions about care progression and discharge readiness. MCG’s technology platforms integrate with electronic health records (EHRs) to automate utilization management, flag delays, and prompt proactive interventions, reducing administrative burden and LOS variability. The overall goal of MCG care guidelines is to support the most appropriate, timely, and efficient care for every patient (and tailored to their specific needs and clinical situation).
Key Benefits of MCG Care Guidelines:
- Efficient Discharge Planning: Improved coordination facilitates safe and timely transitions between care settings.
- Cost Efficiency: Unnecessary utilization of post-acute resources is minimized without compromising care quality.
- Data-Driven Decisions: MCG tools provide benchmarks for LOS and recovery goals, ensuring alignment with best practices.
Real-World Impact of Evidence-Based Pathways
Parrish Healthcare’s use of MCG care guidelines has resulted in measurable improvements in patient outcomes and operational efficiency. By leveraging these pathways, the organization has been able to more accurately determine appropriate lengths of stay, facilitate timely discharges, and provide targeted support when patients encounter complications or setbacks. This approach has helped reduce unnecessary days in SNFs while ensuring that patients receive the level of care they need to recover safely, ultimately leading to lower costs, higher satisfaction, and fewer readmissions. Furthermore, the program’s focus on standardized protocols, data-driven decision-making, and interactive technology platforms makes it inherently scalable and repeatable. Its success can be replicated by other healthcare organizations through the adoption of these structured practices and consistent methodologies, allowing them to achieve similar efficiencies and improved outcomes regardless of their size or geographic location.
Supporting Value-Based Care Metrics and Quality Measures
Value-based care emphasizes improved outcomes and cost efficiency. Parrish Healthcare uses MCG care guidelines to support key metrics central to the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. NCQA HEDIS measures related to care transitions, readmissions, and patient safety are evident in the plan of care. MCG also supports the advancement of health equity by integrating SDoH screening and interventions into the treatment process, enabling the identification and closure of gaps in care for populations at risk.
Key Takeaways for Healthcare Organizations
Healthcare organizations striving for excellence in care transitions and value-based outcomes can draw valuable lessons from Parrish Healthcare’s journey:
- Evidence-based guidelines are instrumental in optimizing discharge planning and reducing care inefficiencies.
- Integrated care models enable seamless communication and coordination, ensuring patient-centric care.
- Personalized recovery plans and targeted interventions lead to better outcomes, lower costs, increased patient engagement, and shared decision-making.
- Proactively managing setbacks with extended recovery guidance prevents unnecessary delays and reduces readmissions.
Conclusion
By implementing MCG care guidelines and fostering integration across the care continuum, Parrish Healthcare exemplifies how patient-focused strategies can bring meaningful change to post-acute transitions. The result is better care for patients, improved financial performance for providers, and alignment with value-based care goals.
– Kristina Weaver, Executive Director of Population Health and Care Transitions, Parrish Healthcare & Emily Ferguson, Managing Editor, MCG Health
Published July 17, 2025. The information contained in this article references MCG care guidelines for those in the specified edition and as of the date of publication and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date of the article.
References
- McGarry BE, Grabowski DC, Ding L, McWilliams JM. Outcomes after shortened skilled nursing facility stays suggest potential for improving post-acute care efficiency. Health Affairs (Millwood). 2021 May;40(5):745-753. DOI: 10.1377/hlthaff.2020.00649.
- Anderson TS, Ayanian JZ, Herzig SJ, Souza J, Landon BE. Gaps in primary care follow-up after hospital discharge among Medicare beneficiaries. Journal of the American Geriatrics Society. 2025 May 2. DOI: 10.1111/jgs.19496. Epub ahead of print.
- Gardner RL, et al. Reducing hospital readmissions through a skilled nursing facility discharge intervention: A pragmatic trial. Journal of the American Medical Directors Association. 2020 Apr;21(4):508-512. DOI: 10.1016/j.jamda.2019.10.001.
- Makam AN, Grabowski DC. Policy in clinical practice: Choosing post-acute care in the new decade. Journal of Hospital Medicine. 2021 Mar;16(3):171-174. DOI: 10.12788/jhm.3577.
- Prusynski RA, Brown C, Johnson JK, Edelstein J. Skilled nursing and home health policy: A primer for the hospital clinician. Archives of Physical Medicine and Rehabilitation. 2025 Feb;106(2):311-320. DOI: 10.1016/j.apmr.2024.08.017.
- Hudson T. The role of social determinants of health in discharge practices. Nursing Clinics of North America. 2021 Sep;56(3):369-378. DOI: 10.1016/j.cnur.2021.04.004.
- Morse-Karzen B, et al. Post-acute care trends and disparities after joint replacements in the United States, 1991-2018: a systematic review. Journal of the American Medical Directors Association. 2024 Sep;25(9):105149. DOI: 10.1016/j.jamda.2024.105149.
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