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- Draft measure specifications: Potentially preventable hospital readmission measures for post-acute care.(Available at:)https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Draft-Measure-Specifications-for-Potentially-Preventable-Hospital-Readmission-Measures-for-PAC-.pdfDate accessed: June 16, 2016
- Measure specifications for measures adopted in the FY 2017 SNF QRP final rule.(Available at:)https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Measure-Specifications-for-FY17-SNF-QRP-Final-Rule.pdfDate accessed: August 23, 2016
- Improving Medicare Post-Acute Care Transformation Act of 2014, PL 113–185.(Available at:)https://www.govtrack.us/congress/bills/113/hr4994Date accessed: September 1, 2016
- Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility.J Am Med Dir Assoc. 2013; 14: 736-740
- Influence of a transitional care clinic on subsequent 30-day hospitalizations and emergency department visits in individuals discharged from a skilled nursing facility.J Am Geriatr Soc. 2013; 61: 137-142
- Restarting the cycle: Incidence and predictors of first acute care use after nursing home discharge.J Am Geriatr Soc. 2014; 62: 79-85
- Federal Register: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research; Final Rule.(Available at:)https://www.gpo.gov/fdsys/pkg/FR-2016-08-05/pdf/2016-18113.pdfDate accessed: August 16, 2017
- Motor and cognitive functional status are associated with 30-day unplanned rehospitalization following post-acute care in Medicare fee-for-service beneficiaries.J Gen Intern Med. 2016; 31: 1427-1434
- Technical Expert Panel Summary Report: Development of functional outcome quality measures for skilled nursing facilities (SNFs).(Available at:)https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-Function-Quality-Measures-TEP-Summary-Report-August-2016.pdfDate accessed: August 23, 2016
- Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Version 1.13.(Available at:)https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-V113.pdfDate: October 2015Date accessed: August 8, 2017
- Association of impaired functional status at hospital discharge and subsequent rehospitalization.J Hosp Med. 2014; 9: 277-282
- Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.JAMA. 2014; 311: 604-614
- Functional impairment and hospital readmission in medicare seniors.JAMA Intern Med. 2015; 175: 559-565
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- Functional improvement among short-stay nursing home residents in the MDS 3.0.J Am Med Dir Assoc. 2015; 16: 470-474
- The Minimum Data Set 3.0 cognitive function scale.Med Care. 2017; 55: e68-e72
- MDS 3.0: brief interview for mental status.J Am Med Dir Assoc. 2012; 13: 611-617
- MDS cognitive performance scale.J Gerontol. 1994; 49: M174-M182
- Evaluation of the CMS-HCC risk adjustment model. Final report.(Available at:)https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Evaluation_Risk_Adj_Model_2011.pdfDate: March 2011Date accessed: December 19, 2016
- 2014 Model Software/ICD-9-CM Mappings. Version 22 CMS-HCC Risk-Adjustment Model.(Available at:)https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.htmlDate accessed: November 11, 2015
The authors declare no conflicts of interest.
The study was funded by the National Institutes of Health (R01AG33134; K05CA134923; R01HD069443; K12HD055929; U54GM104941; P2CHD065702, and P30AG024832), the Agency for Healthcare Research and Quality (R24HS22134), and the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services and Health Policy Research and Training Grant.