Analysis of Functional Recovery in Older Adults Discharged to Skilled Nursing Facilities and Then Home

Abstract

Importance: Although many older adults are discharged to skilled nursing facilities (SNFs) after hospitalization, rates of patients recovery afterward are unknown.

Objective: To examine postacute functional recovery among older adults.

Design, setting, and participants: This cohort study was conducted among older adults treated in SNFs, then at home with home health care (HHC). Participants were a 5% random sample of Medicare fee-for-service beneficiaries discharged to community HHC after SNF stay from 2014 to 2016 with continuous part A and B enrollment in the prior 6 months. Medicare claims data from 2014 to 2016 were used, including inpatient, SNF, hospice, HHC, outpatient, carrier, and durable medical equipment data and Minimum Data Set (MDS) and Outcome Assessment Information Set (OASIS) for SNF and HHC assessments, respectively. Data were analyzed from July 20, 2020, to June 5, 2022.

Exposures: Frailty was measured with a validated claims-based frailty index (CFI) (range, 0-1; higher scores indicate worse frailty) and categorized into not frail (<0.20), mildly frail (0.20-0.29), and moderately to severely frail (≥0.30).

Main outcomes and measures: The primary outcome was functional recovery, defined by discharge from HHC with stable or improved ability to perform activities of daily living (ADL). Recovery status was examined at 15, 30, 45, 60, 75, and 90 days after discharge to HHC using OASIS. Covariates were obtained from the MDS admission file at SNF admission, including age, race and ethnicity, cognitive status, functional status, and geographic region.

Results: Among 105 232 beneficiaries (mean [SD] age, 79.1 [10.6] years; 68 637 [65.2%] women; 8951 Black [8.5%], 3109 Hispanic [3.0%], and 88 583 White [84.2%] individuals), 65 796 individuals (62.5%) were discharged from HHC services with improved function over 90 days of follow-up. Among 39 436 beneficiaries not recovered, 19 612 individuals (49.7%) had mild frailty and 15 818 individuals (40.1%) had moderate to severe frailty. While 10 492 of 17 576 beneficiaries who were not frail recovered by 45 days (59.7%), 10 755 of 32 212 individuals with moderate to severe frailty had recovered (33.4%). Overall, frailty was negatively associated with functional recovery after adjustment for demographic characteristics, geographic census regions, and health-related variables, with a hazard ratio for moderate to severe frailty of 0.62 (95% CI, 0.60-0.63) compared with nonfrailty.

Conclusions and relevance: This study found that recovery after posthospitalization SNF stay was particularly prolonged for individuals with frailty. Functional dependence in activities of daily living remained common among individuals with frailty long after discharge home.

Figure 1.. Cohort Flow Diagram

FFS indicates fee-for-service Medicare; NH, nursing home; SNF, skilled nursing facility; total SNF episodes, the first episodes of care captured in the Minimum Data Set between July 1, 2014, and June 30, 2016, with a length of stay of 1 day or more and 100 days or less, per Center for Medicare & Medicaid services guidelines for determining short stay. Other exclusions include individuals discharged to psychiatric hospitals, inpatient rehabilitation facilities, hospice, and long-term chronic hospitals.

Figure 2.. Functional Recovery Over Time

Functional recovery at various time points after skilled nursing facility discharge to the community is given overall and by claims-based frailty index. Recovery was defined as discharge from home health care services with stable or improved ability to perform activities of daily living. Frailty defined was categorized by claims-based frailty index score as not frail (<0.20), mildly frail (0.21-0.29), or moderately to severely frail (≥0.30).