Functional Status Is Associated With 30-Day Potentially Preventable Readmissions Following Skilled Nursing Facility Discharge Among Medicare Beneficiaries

Abstract

Objectives: The objectives of this study were to determine the association between patients' functional status at discharge from skilled nursing facility (SNF) care and 30-day potentially preventable hospital readmissions, and to examine common reasons for potentially preventable readmissions.

Design: Retrospective cohort study.

Setting: SNFs and acute care hospitals submitting claims to Medicare.

Participants: National cohort of Medicare fee-for-service beneficiaries discharged from SNF care between July 15, 2013, and July 15, 2014 (n = 693,808). Average age was 81.4 (SD 8.1) years, 67.1% were women, and 86.3% were non-Hispanic white.

Measurements: Functional items from the Minimum Data Set 3.0 were categorized into self-care, mobility, and cognition domains. We used specifications for the SNF potentially preventable 30-day postdischarge readmission quality metric to identify potentially preventable readmissions.

Results: The overall observed rate of 30-day potentially preventable readmissions following SNF discharge was 5.7% (n = 39,318). All 3 functional domains were independently associated with potentially preventable readmissions in the multivariable models. Odds ratios for the most dependent category versus the least dependent category from multilevel models adjusted for patients' sociodemographic and clinical characteristics were as follows: mobility, 1.54 (95% confidence interval [CI] 1.49-1.59); self-care, 1.50 (95% CI 1.44-1.55); and cognition, 1.12 (95% CI 1.04-1.20). The 5 most common conditions were congestive heart failure (n = 7654, 19.5%), septicemia (n = 7412, 18.9%), urinary tract infection/kidney infection (n = 4297, 10.9%), bacterial pneumonia (n = 3663, 9.3%), and renal failure (n = 3587, 9.1%). Across all 3 functional domains, septicemia was the most common condition among the most dependent patients and congestive heart failure among the least dependent.

Conclusions: Patients with functional limitations at SNF discharge are at increased risk of hospital readmissions considered potentially preventable. Future research is needed to determine whether improving functional status reduces risk of potentially preventable readmissions among this vulnerable population.

Keywords: Mobility; chronic conditions; cognition; infection; self-care.

Figure 1

Flow chart presenting number of eligible cases remaining at each step as exclusion criteria applied. Percentages are percent remaining from the previous step. Abbreviations: SNF, skilled nursing facility; PPS, prospective payment system; MDS, Resident Assessment Instrument Minimum Date Set 3.0; IRF, inpatient rehabilitation facility. * 1^st discharge was selected if patient had more than one over the study period. † Based on assessment windows for the scheduled PPS MDS assessments. ‡ ‘Index hospitalization’ is an acute care stay over the 30 days prior to SNF admission. § ‘Study period’ refers to the 6 months prior to the index hospitalization through the 32 days post-discharge for each SNF stay.