Can I Stay, or Must I Go Now? A Cohort Study of Discharge Appeals in a Post-Acute Skilled Nursing Facility

Abstract

Objectives: Patients admitted to a skilled nursing facility (SNF) for short-term rehabilitation after hospitalization often feel unprepared to return home and may appeal discharge dates set by SNFs and/or insurers. There are additional concerns that Medicare Advantage (MA) insurers may be more aggressive about discharging patients earlier compared with traditional Medicare. Yet, little has been published on the characteristics of patients who appeal and their outcomes.

Design: Retrospective cohort study.

Setting and participants: Participants included patients admitted to a single SNF after hospitalization from March 1, 2024, to March 31, 2025, who filed discharge appeals.

Methods: We collected information via chart reviews on patient demographics (eg, age, insurance coverage), comorbidities, function scores, and documented reasons for appeal. We also identified outcomes following appeal (eg, 30-day rehospitalization, death).

Results: Of 453 eligible SNF admissions, 47 (10.4%) patients filed 58 appeals [mean age 79.3 (SD = 10.6), 25 (53.2%) female, 9 (19.1%) Asian, 7 (14.9%) Black, 20 (42.6%) in traditional Medicare, 27 (57.4%) in MA]. Median (IQR) time from SNF admission to first appeal was 19.0 (15.0-30.5) days. Eleven patients (23.4%) won their appeals. The median (IQR) time from first appeal to discharge was 8 (7-13) and 4 (3-8) days among patients who won their appeals vs those who lost their final appeal, respectively. The 30-day rehospitalization and 30-day mortality rates among those who won their appeals were 0% (n = 0 of 11) and 18.2% (n = 2 of 11), respectively. Among those who lost their final appeal, rates were 27.8% (n = 10 of 36) and 0% (n = 0 of 36), respectively. The most common reason for appealing was patient and/or family/caregiver concern about discharge readiness (n = 28, 59.6%).

Conclusions and implications: In this single-SNF study, 10% of post-acute patients appealed their discharge, commonly citing concerns about discharge readiness, with most ultimately losing their final appeal. This study lays the groundwork for future research examining appeals processes and outcomes on a broader scale.

Keywords: Medicare Advantage; Skilled nursing facility; discharge appeal; post-acute care.