Skilled Nursing Providers Team With Home Health For Better Outcomes

Skilled nursing facilities may want to ensure they have strong relationships with home health care partners, as a recent study finds home health care visits play a significant role in reducing readmissions after a SNF discharge.

The study, “Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission,” found that a home health visit was the best way to reduce the likelihood of a readmission. Starting in 2018, Medicare will penalize SNFs in addition to hospital with re-hospitalizations within 30 days of discharge from the hospital.

Researchers from the Indiana University for Aging Research and the Regenstrief Institute looked at 1,500 “community-dwelling older adults” who were discharged from a SNF before they went home after a hospital visit.


In fact, a home health visit “immediately” after a discharge from a SNF was the factor “most significantly associated with lower readmission rates.” And there are many patients that could benefit.

And SNFs could be at a big risk, as one of five discharges of older adults look like this: Patients are admitted the hospital, discharged to a SNF, and then discharged home.

“We aren’t saying that seeing your physician after discharge form the SNF isn’t important,” Jennifer Carnahan, an investigator at the IU Center for Aging Research and Regenstrief Institute, said. “We are saying that having a home health worker visit as soon as you return home appears to be more significant in reducing hospital readmissions.”


Past studies have revealed the following up with a doctor upon returning home from a SNF can also be beneficial, but, the results are equivocal at most, Carnahan noted. However, compared to a home health care visit, meeting with a physician is significantly more expensive and doesn’t have the same strong association with lower discharges.

SNFs typically arrange home health care visits prior to an older adult’s discharge to home, according to the study. Many home health care agencies find SNFs to be strong referral partners as a result of this relationship.

Authors of the study used the findings to promote greater access to home health care, urging policymakers to pay attention on ways to cut costs by keeping patients at home.

Written by Amy Baxter

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