Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

Published:December 20, 2015DOI:



      Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes.


      Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003–2009.


      The MCBS is a nationally representative survey of beneficiaries matched with claims data.


      Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation.


      Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics.


      Hospital readmission during the PAC stay, return to community residence, and all-cause mortality.


      Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21–7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39–1.92), and for-profit PAC ownership (1.43, 1.21–1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60–2.54; 100 days: OR 3.79, 95% CI 3.13–4.59).


      Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.


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        • Halm E.A.
        • Magaziner J.
        • Hannan E.L.
        • et al.
        Frequency and impact of active clinical issues and new impairments on hospital discharge in patients with hip fracture.
        Arch Intern Med. 2003; 163: 108-113
        • Halm E.A.
        • Fine M.J.
        • Kapoor W.N.
        • et al.
        Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia.
        Arch Intern Med. 2002; 162: 1278-1284
        • Qian X.
        • Russell L.B.
        • Valiyeva E.
        • Miller J.E.
        “Quicker and sicker” under Medicare's prospective payment system for hospitals: New evidence on an old issue from a national longitudinal survey.
        Bull Econ Res. 2011; 63: 1-27
        • Kosecoff J.
        • Kahn K.L.
        • Rogers W.H.
        • et al.
        Prospective payment system and impairment at discharge. The “quicker-and-sicker” story revisited.
        JAMA. 1990; 264: 1980-1983
        • Burke R.E.
        • Juarez-Colunga E.
        • Levy C.
        • et al.
        Rise of post-acute care facilities as a discharge destination of US hospitalizations.
        JAMA Intern Med. 2015; 175: 295-296
        • Chandra A.
        • Dalton M.A.
        • Holmes J.
        Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings.
        Health Aff (Millwood). 2013; 32: 864-872
      1. A Data Book: Health care spending and the Medicare Program. Medicare Payment Advisory Commission, Washington, DC2015 (Available at:) (Accessed November 30, 2015)
        • Mor V.
        • Intrator O.
        • Feng Z.
        • Grabowski D.C.
        The revolving door of rehospitalization from skilled nursing facilities.
        Health Aff (Millwood). 2010; 29: 57-64
      2. OIG. Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries, OEI-06–11–00370, 2014. Available at: Accessed March 5, 2014.

        • Kramer A.
        • Fish R.
        • Min S.
        Community discharge and rehospitalization outcome measures.
        Medicare Payment Advisory Commission, Washington, DC2013 (Available at:) (Accessed November 30, 2015)
        • Mechanic R.
        Post-acute care—the next frontier for controlling Medicare spending.
        N Engl J Med. 2014; 370: 692-694
        • Ackerly D.C.
        • Grabowski D.C.
        Post-acute care reform—beyond the ACA.
        N Engl J Med. 2014; 370: 689-691
        • Kansagara D.
        • Englander H.
        • Salanitro A.
        • et al.
        Risk prediction models for hospital readmission: A systematic review.
        JAMA. 2011; 306: 1688-1698
        • Dharmarajan K.
        • Hsieh A.F.
        • Lin Z.
        • et al.
        Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        JAMA. 2013; 309: 355-363
        • Ottenbacher K.J.
        • Karmarkar A.
        • Graham J.E.
        • et al.
        Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.
        JAMA. 2014; 311: 604-614
        • Graham K.L.
        • Wilker E.H.
        • Howell M.D.
        • et al.
        Differences between early and late readmissions among patients: A cohort study.
        Ann Intern Med. 2015; 162: 741-749
        • Coleman E.A.
        • Min S.
        • Chomiak A.
        • Kramer A.M.
        Posthospital care transitions: Patterns, complications, and risk identification.
        Health Serv Res. 2004; 39: 1449-1465
        • Greysen S.R.
        • Stijacic Cenzer I.
        • Auerbach A.D.
        • Covinsky K.E.
        Functional impairment and hospital readmission in medicare seniors.
        JAMA Intern Med. 2015; 175: 559-565
        • Li B.
        • Evans D.
        • Faris P.
        • et al.
        Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases.
        BMC Health Serv Res. 2008; 8: 12
        • Cowen M.E.
        • Dusseau D.J.
        • Toth B.G.
        • et al.
        Casemix adjustment of managed care claims data using the clinical classification for health policy research method.
        Med Care. 1998; 36: 1108-1113
        • Chodosh J.
        • Edelen M.O.
        • Buchanan J.L.
        • et al.
        Nursing home assessment of cognitive impairment: Development and testing of a brief instrument of mental status.
        J Am Geriatr Soc. 2008; 56: 2069-2075
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: The Barthel Index.
        Md State Med J. 1965; 14: 61-65
        • Levy C.
        • Kheirbek R.
        • Alemi F.
        • et al.
        Predictors of six-month mortality among nursing home residents: Diagnoses may be more predictive than functional disability.
        J Palliat Med. 2015; 18: 100-106
        • Salpeter S.R.
        • Malter D.S.
        • Luo E.J.
        • et al.
        Systematic review of cancer presentations with a median survival of six months or less.
        J Palliat Med. 2012; 15: 175-185
        • King B.J.
        • Gilmore-Bykovskyi A.L.
        • Roiland R.A.
        • et al.
        The consequences of poor communication during transitions from hospital to skilled nursing facility: A qualitative study.
        J Am Geriatr Soc. 2013; 61: 1095-1102
        • Ouslander J.G.
        • Lamb G.
        • Perloe M.
        • et al.
        Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760–761].
        J Am Geriatr Soc. 2010; 58: 627-635
        • Boockvar K.
        • Fishman E.
        • Kyriacou C.K.
        • et al.
        Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities.
        Arch Intern Med. 2004; 164: 545-550
        • Boockvar K.S.
        • Fridman B.
        • Marturano C.
        Ineffective communication of mental status information during care transfer of older adults.
        J Gen Intern Med. 2005; 20: 1146-1150
        • Popejoy L.
        • Galambos C.
        • Vogelsmeier A.
        Hospital to nursing home transition challenges: Perceptions of nursing home staff.
        J Nurs Care Qual. 2014; 29: 103-109
        • Tjia J.
        • Bonner A.
        • Briesacher B.A.
        • et al.
        Medication discrepancies upon hospital to skilled nursing facility transitions.
        J Gen Intern Med. 2009; 24: 630-635
        • Burke R.E.
        • Juarez-Colunga E.
        • Levy C.
        • et al.
        Patient and hospitalization characteristics associated with increased postacute care facility discharges from US hospitals.
        Med Care. 2015; 53: 492-500
      3. Smith L, West S, Coots L, et al. Skilled Nursing Facility Readmission Measure (SNFRM) NQF #2510: All-cause risk-standardized readmission measure - SNFRM-Technical-Report-3252015.pdf. Available at: Accessed September 11, 2015.

        • Rahman M.
        • Tyler D.
        • Thomas K.S.
        • et al.
        Higher Medicare SNF care utilization by dual-eligible beneficiaries: Can Medicaid long-term care policies be the answer?.
        Health Serv Res. 2015; 50: 161-179
        • Kane R.L.
        Finding the right level of posthospital care: “We didn't realize there was any other option for him”.
        JAMA. 2011; 305: 284-293
        • Kane R.L.
        • Bershadsky B.
        • Bershadsky J.
        Who recommends long-term care matters.
        Gerontologist. 2006; 46: 474-482
        • Ward K.T.
        • Eslami M.S.
        • Garcia M.B.
        • McCreath H.E.
        Do internal medicine residents know enough about skilled nursing facilities to orchestrate a good care transition?.
        J Am Med Dir Assoc. 2014; 15: 841-843
        • Neuman M.D.
        • Wirtalla C.
        • Werner R.M.
        Association between skilled nursing facility quality indicators and hospital readmissions.
        JAMA. 2014; 312: 1542-1551
        • O'Neill C.
        • Harrington C.
        • Kitchener M.
        • Saliba D.
        Quality of care in nursing homes: An analysis of relationships among profit, quality, and ownership.
        Med Care. 2003; 41: 1318-1330
        • Hillmer M.P.
        • Wodchis W.P.
        • Gill S.S.
        • et al.
        Nursing home profit status and quality of care: Is there any evidence of an association?.
        Med Care Res Rev. 2005; 62: 139-166
        • Lage D.E.
        • Rusinak D.
        • Carr D.
        • et al.
        Creating a network of high-quality skilled nursing facilities: Preliminary data on the postacute care quality improvement experiences of an accountable care organization.
        J Am Geriatr Soc. 2015; 63: 804-808
        • Barnes D.E.
        • Mehta K.M.
        • Boscardin W.J.
        • et al.
        Prediction of recovery, dependence or death in elders who become disabled during hospitalization.
        J Gen Intern Med. 2013; 28: 261-268
        • Hoyer E.H.
        • Needham D.M.
        • Atanelov L.
        • et al.
        Association of impaired functional status at hospital discharge and subsequent rehospitalization.
        J Hosp Med. 2014; 9: 277-282
        • Peel N.M.
        • Navanathan S.
        • Hubbard R.E.
        Gait speed as a predictor of outcomes in post-acute transitional care for older people.
        Geriatr Gerontol Int. 2014; 14: 906-910
        • Sager M.A.
        • Franke T.
        • Inouye S.K.
        • et al.
        Functional outcomes of acute medical illness and hospitalization in older persons.
        Arch Intern Med. 1996; 156: 645-652
        • Shih S.L.
        • Gerrard P.
        • Goldstein R.
        • et al.
        Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients.
        J Gen Intern Med. 2015; 30: 1688-1695
        • Kane R.L.
        • Lin W.-C.
        • Blewett L.A.
        Geographic variation in the use of post-acute care.
        Health Serv Res. 2002; 37: 667-682
        • Lenze E.J.
        • Host H.H.
        • Hildebrand M.W.
        • et al.
        Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: A randomized-controlled trial.
        J Am Med Dir Assoc. 2012; 13: 708-712
        • Falvey J.R.
        • Mangione K.K.
        • Stevens-Lapsley J.E.
        Rethinking hospital-associated deconditioning: Proposed paradigm shift.
        Phys Ther. 2015; 95: 1307-1315
        • Jette D.U.
        • Warren R.L.
        • Wirtalla C.
        The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities.
        Arch Phys Med Rehabil. 2005; 86: 373-379
        • Walsh T.S.
        • Salisbury L.G.
        • Merriweather J.L.
        • et al.
        Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: The RECOVER randomized clinical trial.
        JAMA Intern Med. 2015; 175: 901-910
        • Goodwin J.S.
        • Howrey B.
        • Zhang D.D.
        • Kuo Y.-F.
        Risk of continued institutionalization after hospitalization in older adults.
        J Gerontol A Biol Sci Med Sci. 2011; 66: 1321-1327
        • Newhouse J.P.
        • Garber A.M.
        Geographic variation in health care spending in the United States: Insights from an Institute of Medicine report.
        JAMA. 2013; 310: 1227-1228
        • Schumacher D.N.
        • Dobkin E.D.
        Medicare spending per beneficiary.
        Health Aff (Millwood). 1878; 2014: 33
        • Ouslander J.G.
        • Lamb G.
        • Tappen R.
        • et al.
        Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project.
        J Am Geriatr Soc. 2011; 59: 745-753
        • Givens J.L.
        • Mitchell S.L.
        • Kuo S.
        • et al.
        Skilled nursing facility admissions of nursing home residents with advanced dementia.
        J Am Geriatr Soc. 2013; 61: 1645-1650
        • Barnes C.
        • Conner D.
        • Legault L.
        • et al.
        Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community.
        Arch Phys Med Rehabil. 2004; 85: 1602-1607
        • Levy C.R.
        • Fish R.
        • Kramer A.
        Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit.
        J Am Geriatr Soc. 2005; 53: 2060-2068
        • Levy C.R.
        • Fish R.
        • Kramer A.M.
        Site of death in the hospital versus nursing home of Medicare skilled nursing facility residents admitted under Medicare's Part A Benefit.
        J Am Geriatr Soc. 2004; 52: 1247-1254