Original Study| Volume 22, ISSUE 12, P2565-2570.e4, December 2021

Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey

  • Robert E. Burke
    Address correspondence to Robert E. Burke, MD, MS, 423 Guardian Drive, 1232 Blockley Hall, Philadelphia, PA 19104, USA.
    Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA

    Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
    Search for articles by this author
  • Jessica Phelan
    Harvard T.H. Chan School of Public Health, Department of Health Policy, Boston, MA, USA
    Search for articles by this author
  • Dori Cross
    University of Minnesota School of Public Health, Department of Health Policy and Management, Minneapolis, MN, USA
    Search for articles by this author
  • Rachel M. Werner
    Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA

    Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
    Search for articles by this author
  • Julia Adler-Milstein
    University of California San Francisco, Department of Medicine and Center for Clinical Informatics and Improvement Research, San Francisco, CA, USA
    Search for articles by this author



      Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs.


      Cross-sectional survey.

      Setting and Participants

      A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF.


      We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics.


      Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P = .049).

      Conclusions and Implications

      These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mor V.
        • Intrator O.
        • Feng Z.
        • Grabowski D.C.
        The revolving door of rehospitalization from skilled nursing facilities.
        Health Aff Proj Hope. 2010; 29: 57-64
        • Burke R.E.
        • Greysen S.R.
        Reducing SNF readmissions: At what cost?.
        J Hosp Med. 2018; 13: 285-286
        • Burke R.E.
        • Whitfield E.A.
        • Hittle D.
        • et al.
        Hospital readmission from post-acute care facilities: Risk factors, timing, and outcomes.
        J Am Med Dir Assoc. 2016; 17: 249-255
        • McWilliams J.M.
        • Gilstrap L.G.
        • Stevenson D.G.
        • et al.
        Changes in postacute care in the Medicare Shared Savings Program.
        JAMA Intern Med. 2017; 177: 518-526
        • Zhu J.M.
        • Navathe A.
        • Yuan Y.
        • et al.
        Medicare’s bundled payment model did not change skilled nursing facility discharge patterns.
        Am J Manag Care. 2019; 25: 329-334
        • Zhu J.M.
        • Patel V.
        • Shea J.A.
        • et al.
        Hospitals using bundled payment report reducing skilled nursing facility use and improving care integration.
        Health Aff Proj Hope. 2018; 37: 1282-1289
        • Joynt Maddox K.E.
        • Orav E.J.
        • Zheng J.
        • Epstein A.M.
        Post-acute care after joint replacement in Medicare’s bundled payments for care improvement initiative.
        J Am Geriatr Soc. 2019; 67: 1027-1035
        • Jubelt L.E.
        • Goldfeld K.S.
        • Chung W.-Y.
        • et al.
        Changes in discharge location and readmission rates under Medicare bundled payment.
        JAMA Intern Med. 2016; 176: 115-117
        • Colla C.H.
        • Lewis V.A.
        • Bergquist S.L.
        • Shortell S.M.
        Accountability across the continuum: The participation of postacute care providers in accountable care organizations.
        Health Serv Res. 2016; 51: 1595-1611
        • Kim K.L.
        • Li L.
        • Kuang M.
        • et al.
        Changes in hospital referral patterns to skilled nursing facilities under the hospital readmissions reduction program.
        Med Care. 2019; 57: 695-701
        • Liao J.M.
        • Konetzka R.T.
        • Werner R.M.
        Trends in hospital-SNF relationships in the care of Medicare beneficiaries.
        Healthc (Amst). 2018; 6: 175-179
        • Konetzka R.T.
        • Stuart E.A.
        • Werner R.M.
        The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes.
        J Health Econ. 2018; 61: 244-258
        • Konetzka R.T.
        • Werner R.M.
        Relationships between acute and postacute care providers: Measurement and estimation.
        Health Serv Res. 2017; 52: 1621-1628
        • Rahman M.
        • Foster A.D.
        • Grabowski D.C.
        • et al.
        Effect of hospital-SNF referral linkages on rehospitalization.
        Health Serv Res. 2013; 48: 1898-1919
        • Kennedy G.
        • Lewis V.A.
        • Kundu S.
        • et al.
        Accountable care organizations and post-acute care: A focus on preferred SNF networks.
        Med Care Res Rev. 2020; 77: 312-323
        • Shield R.
        • Winblad U.
        • McHugh J.
        • et al.
        Choosing the best and scrambling for the rest: Hospital-nursing home relationships and admissions to post-acute care.
        J Appl Gerontol. 2019; 38: 479-498
        • Lawrence E.
        • Casler J.-J.
        • Jones J.
        • et al.
        Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing.
        Health Care Manage Rev. 2020; 45: 353-363
        • Rahman M.
        • Gadbois E.A.
        • Tyler D.A.
        • Mor V.
        Hospital-skilled nursing facility collaboration: A mixed-methods approach to understanding the effect of linkage strategies.
        Health Serv Res. 2018; 53: 4808-4828
        • 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
      1. Shaping Long Term Care in America Project at Brown University funded in part by the National Institute on Aging (1P01AG027296). Available at: Accessed November 2, 2020.

        • Everson J.
        • Lee S.-Y.D.
        • Friedman C.P.
        Reliability and validity of the American Hospital Association’s national longitudinal survey of health information technology adoption.
        J Am Med Inform Assoc. 2014; 21: e257-e263
        • Ayele R.
        • Manges K.A.
        • Leonard C.
        • et al.
        How context influences hospital readmissions from skilled nursing facilities: A rapid ethnographic study.
        J Am Med Dir Assoc. 2020; 22: 1248-1254
        • Burke R.E.
        • Canamucio A.
        • Glorioso T.J.
        • et al.
        Variability in transitional care outcomes across hospitals discharging veterans to skilled nursing facilities.
        Med Care. 2020; 58: 301-306
        • Manges K.A.
        • Ayele R.
        • Leonard C.
        • et al.
        Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: A rapid ethnographic approach.
        BMJ Qual Saf. 2020;
        • 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
        • Werner R.M.
        • Konetzka R.T.
        Trends in post-acute care use among Medicare beneficiaries: 2000 to 2015.
        JAMA. 2018; 319: 1616-1617