Accountable Care Organizations, Skilled Nursing Facilities, and Nurse Practitioners

Moving From Broad Themes to Actionable Care Redesign

In this issue of Medical Care, Meddings et al¹ explore the role of nurse practitioners (NPs) in averting post-skilled nursing facility (SNF) readmissions for Medicare beneficiaries inside and outside of accountable care organizations (ACOs). This work wades into the complexity of transforming the US health care system through value-based payment models, highlighting the need for adaptive staffing models that leverage the skills of a clinically diverse workforce. As the authors suggest, NPs have an important role to play in care transformation, offering patient-centered, integrated services, often to the most complex patients.¹ Moving forward, we need to drill into and expand the specific combinations of clinical and institutional care that leads to positive outcomes. Even better, we need to leverage these pockets of success to drive the system toward new clinical staffing configurations and care models.

Population health payment models as we know them today originated in the Affordable Care Act of 2010. The Medicare Shared Savings Program (MSSP) is the largest model with 456 ACOs and 10.9 million assigned beneficiaries as of 2023.² At its heart, an ACO is a group of providers taking responsibility for the health care of a cohort of patients. ACOs come in many organizational forms and not all include hospitals. In fact, as many as 45% are clinician-led, with only indirect connections to the hospitals and SNFs that treat their patients.³ Size and complexity vary, with some ACOs spanning multiple states.

The indirect connections between ACOs and institutional providers pose a challenge when it comes to patient-centered care. Specifically, ACOs cannot limit patients to specific postacute care providers and many have to interact with dozens of different facilities to find beds for all of their beneficiaries. Some ACOs have created preferred SNF networks, gently steering patients to providers where they may have overlapping staff, shared trainings, or a bi-directional flow of information. There is evidence of positive steering^4,5 and decreased readmissions rates within ACOs.⁶ At the Institute for Accountable Care (IAC), we have noted that the mean SNF stay costs for ACO beneficiaries in 2021 was $16,362, compared with $20,954 for fee-for-service beneficiaries, further hinting at some form of positive steering to efficient facilities.

NPs play a prominent and growing role both within ACOs and SNFs.⁷ They are most likely to be found in larger ACOs, those in rural areas or in ACOs located in states with full practice authority.⁸ Less is known about NP staffing within SNFs, in part because they may be employed by separate organizations, coming to the SNF to provide primary or behavioral health care. We do know that staffing mix matters, including the benefits of team-based care and higher clinical intensity.^9,10

Meddings and colleagues find that ACO-attributed beneficiaries are more likely to receive NP care during a SNF stay as compared with fee-for-service beneficiaries. Furthermore, those receiving SNF-based NP care have lower readmissions (about 1 percentage point).¹ Others have noted similar findings.^8,11 Given the complexity of the US health care delivery system, the diversity in ACO structures and variations in the health care workforce from market-to-market we are left with the important question: how? How do ACOs and SNFs attract and retain NPs? How do they gear patients to more efficient SNFs? How do SNFs achieve more efficient care?

The authors of this study work hard to untangle the impact of ACOs and NPs on acute events, even considering the impact of NP exposure on outcomes. This type of systems level signal is important, but the next step is a deeper understanding of what is working well within specific health care markets, carefully considering the impact of the regulatory environment, workforce and staffing, organizational structures, and payment models.