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postacute care, skilled nursing facilities, value-based payment reforms



  1. Lawrence, Emily
  2. Casler, Jessica-Jean
  3. Jones, Jacqueline
  4. Leonard, Chelsea
  5. Ladebue, Amy
  6. Ayele, Roman
  7. Cumbler, Ethan
  8. Allyn, Rebecca
  9. Burke, Robert E.


Background: Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care.


Purpose: The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms.


Methods: We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach.


Results: We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients.


Conclusions: We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing.


Practice Implications: SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.