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

Jennifer L. Carnahan, James E. Slaven, Christopher M. Callahan, Wanzhu Tu, Alexia M. Torke

Research output: Contribution to journalArticle

11 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)853-859
Number of pages7
JournalJournal of the American Medical Directors Association
Issue number10
StatePublished - Oct 1 2017



  • Care transitions
  • home care
  • hospital readmission
  • primary care
  • skilled nursing facility

ASJC Scopus subject areas

  • Nursing(all)
  • Health Policy
  • Geriatrics and Gerontology

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