Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Abstract

Background: Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

Objective: To identify whether early post-SNF discharge care reduces likelihood of 30-day hospital readmissions.

Design: Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.

Participants/setting: Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).

Measurements: The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.

Results: Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).

Conclusion: For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention.

Keywords: Care transitions; home care; hospital readmission; primary care; skilled nursing facility.

Figure 1. Hospital to SNF to Home Trajectory

We describe two populations: 1) the Hospital to Home Group which traverses Arrow 1A followed by Arrow 1B and; 2) the SNF to Home Group which traverses Arrows 1A, 2A, and 3A.

Figure 2. Primary Cohort Flowchart

*Hospital admit dates are: 1/1/07-6/16/10. SNF subjects must be discharged from the SNF prior to 10/1/10. ** Percentages reported are the percent taken from the previous population on the figure; thus, 26.2% of the total OATS cohort was hospitalized during our study timeframe.

Figure 3. Product limit estimator graphs

3A.: Hospital readmissions for those who had home health within a week versus those who did not. Wilcoxon p-value for equality across state: p<0.001 3B.: Hospital readmissions for those who had outpatient visits within a week versus those who did not. Wilcoxon p-value for equality across state: p=0.252

Figure 3. Product limit estimator graphs

3A.: Hospital readmissions for those who had home health within a week versus those who did not. Wilcoxon p-value for equality across state: p<0.001 3B.: Hospital readmissions for those who had outpatient visits within a week versus those who did not. Wilcoxon p-value for equality across state: p=0.252