Hospitalization Following Discharge From a Skilled Nursing Facility (HFS)

For persons 65 years of age and older, the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis within 30 days and within 60 days following a skilled nursing facility (SNF) discharge to the community.

Why It Matters

Hospital admission and readmission events during and after skilled nursing care are important to consider as they are associated with worse patient outcomes ⁽¹⁾. For an increasing proportion of beneficiaries, skilled nursing care is essential to safe and successful transitions back to the community. The SNF population generally includes older beneficiaries with increased comorbidities, more medications and more severe illness. Patients readmitted to a hospital from inpatient rehabilitation facilities (IRF) and SNFs were found to be twice as likely to die within 30 days and nearly four times as likely to die within 100 days than patients without a readmission event. Hospital readmission was found to be the strongest predictor of death among older adults requiring skilled nursing care (unadjusted hazard ratio 28.2, p-value <0.0001) ⁽²⁾.

Among Medicare beneficiaries, 1 in 10 SNF stays results in a potentially preventable readmission during the SNF stay and 1 in 20 results in a potentially preventable readmission after SNF discharge ⁽³⁾.

Health plans are accountable for a member’s entire episode of care including care prior to SNF admission, during SNF stay and after SNF discharge. Plans can reduce hospitalizations and readmissions for members requiring skilled nursing care in several ways, including strengthening care transitions (e.g., share medication reconciliations and diagnostic workups) between hospitals and SNFs; promoting admissions to SNFs with appropriate staffing levels and technical capabilities; and coordinating follow-up care with primary care providers to support members with complex care needs. Many health systems and organizations have made financial and resource investments in the post-acute care sector to improve outcomes, reduce readmissions and control expenditures.

Historical Results – National Averages

Performance results for this measure are currently unavailable. Visit our Quality Compass page to explore data licensing options and gain access to detailed performance results for this measure.