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Background <p>Post-acute care management programs are designed to optimize transitions from hospitals to skilled nursing facilities (SNFs) and reduce acute care utilization but largely focus on Medicare beneficiaries. Little is known about the effectiveness of these programs for uninsured patients, many of whom are discharged to SNFs because of complex medical and social needs that preclude safe discharge to home. We aimed to develop and evaluate the effectiveness of a post-acute care management program for uninsured patients discharged to SNFs.</p> Methods <p>We developed a multi-component post-acute care management program to address care coordination, discharge planning, care integration, and information transfer at John Peter Smith Hospital (JPS). We used electronic health records and claims data to identify adults discharged to one of three affiliated SNFs between October 2017 and September 2023. The intervention group received the post-acute care management program. The historical comparison group received usual care prior to program implementation. We used propensity score matching and G-computation to address confounding bias and estimate mean differences (MDs) or risk differences (RDs) and corresponding 95% confidence limits (CL) for SNF length of stay (LOS), 30-day inpatient readmission, 30-day emergency department (ED) admission, and 30-day primary care linkage following SNF discharge.</p> Results <p>Our study population comprised 566 patients. The mean SNF LOS was 20.1 days for the intervention group and 28.9 days for the comparison group (MD=-8.83, 95% CL: -9.52, -8.13). Risk of 30-day readmission was 18.0% for the intervention group and 19.8% for the comparison group (RD=-1.75%, 95% CL: -3.04%, -0.466%). Risk of 30-day ED admission was 17.7% for the intervention group and 18.3% for the comparison group (RD=-0.678%, 95% CL: -1.94%, 0.586%). Risk of 30-day primary care linkage post-SNF discharge was 51.6% for the intervention group and 49.8% for the comparison group (RD = 1.83%, 95% CL: 0.406%, 3.26%).</p> Conclusions <p>Our post-acute care management program reduced SNF LOS and inpatient readmission, while increasing linkage to primary care among uninsured patients discharged to SNFs. This program may be an option for hospitals seeking strategies to enhance transitional care for uninsured patients discharged to SNFs but should be tested in other settings.</p>

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Effects of a post-acute care management program on subsequent acute care utilization for hospitalized patients discharged to skilled nursing facilities

  • 期刊论文

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  • 发表日期：

    2026年1月7日

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  • Devon Armstrong,
  • Afiba M.-A. Agovi,
  • Aaron W. Gehr,
  • Matthew Cvitanovich,
  • Elyse McNamara-Pittler,
  • Nydia Goodier,
  • Kendra Hasty,
  • Amy Govea,
  • Maria Woods,
  • Rohit P. Ojha

摘要

Background

Post-acute care management programs are designed to optimize transitions from hospitals to skilled nursing facilities (SNFs) and reduce acute care utilization but largely focus on Medicare beneficiaries. Little is known about the effectiveness of these programs for uninsured patients, many of whom are discharged to SNFs because of complex medical and social needs that preclude safe discharge to home. We aimed to develop and evaluate the effectiveness of a post-acute care management program for uninsured patients discharged to SNFs.

Methods

We developed a multi-component post-acute care management program to address care coordination, discharge planning, care integration, and information transfer at John Peter Smith Hospital (JPS). We used electronic health records and claims data to identify adults discharged to one of three affiliated SNFs between October 2017 and September 2023. The intervention group received the post-acute care management program. The historical comparison group received usual care prior to program implementation. We used propensity score matching and G-computation to address confounding bias and estimate mean differences (MDs) or risk differences (RDs) and corresponding 95% confidence limits (CL) for SNF length of stay (LOS), 30-day inpatient readmission, 30-day emergency department (ED) admission, and 30-day primary care linkage following SNF discharge.

Results

Our study population comprised 566 patients. The mean SNF LOS was 20.1 days for the intervention group and 28.9 days for the comparison group (MD=-8.83, 95% CL: -9.52, -8.13). Risk of 30-day readmission was 18.0% for the intervention group and 19.8% for the comparison group (RD=-1.75%, 95% CL: -3.04%, -0.466%). Risk of 30-day ED admission was 17.7% for the intervention group and 18.3% for the comparison group (RD=-0.678%, 95% CL: -1.94%, 0.586%). Risk of 30-day primary care linkage post-SNF discharge was 51.6% for the intervention group and 49.8% for the comparison group (RD = 1.83%, 95% CL: 0.406%, 3.26%).

Conclusions

Our post-acute care management program reduced SNF LOS and inpatient readmission, while increasing linkage to primary care among uninsured patients discharged to SNFs. This program may be an option for hospitals seeking strategies to enhance transitional care for uninsured patients discharged to SNFs but should be tested in other settings.