Home Health Diversions from Skilled Nursing Facilities Concentrated in Higher-Income Areas

Hip replacements form a key pillar of skilled nursing facility referrals, while large structural shifts to home health have eaten into lengths of stay. But whether or not a senior receives SNF care after the surgery may depend largely on where he or she lives.

A new study points to patients from higher income neighborhoods opting for home care — and those from disadvantaged areas with increased likelihood of being discharged to skilled nursing and inpatient rehab facilities.

The findings may indicate that hospitals prefer to discharge certain patients to home health — and a possible loss for nursing and rehab facilities. Since the study is preliminary, results could also mean an increase in reimbursements associated lower-income residents.


“With the aging of the population, elective total hip replacement has become one of the fastest-growing procedures to manage severe osteoarthritis,” Dr. Bella Mehta, a rheumatologist at The Hospital for Special Surgery (HSS) in New York City, said. “By 2030, the number of hip replacements is expected to reach 572,000 annually in the US. Medicare, the largest payer of joint replacement surgery, has introduced several payment reform models that target discharge destination and risk of hospital readmission after surgery.”

About 85,000 patients were identified in the Pennsylvania Health Care Cost Containment Council database who had undergone elective hip replacement surgery between 2012 and 2016. Using U.S. Census data, researchers deduced a particular geography’s level of socioeconomic hardship to health outcomes.

Although the study found that community deprivation was linked to home or outbound post-care, 90-day hospital readmission remained unaffected.


Mehta confirmed to SNN the high statistical increases for poorer patients being discharged outside of the home, with a:

  • 47% increase in probability among those aged 65 and younger from deprived communities of being discharged to a post-op institution compared to those in affluent communities
  • 31% increase in probability among those aged 65 and older from deprived communities of being discharged to a post-op institution compared to those in affluent communities

Results may be connected to patients having less access to resources and community support in lower-come locales. Discharging these patients to outside facilities may be perceived by clinicians as the most secure option.

In fact, skilled nursing and rehab facilities are most likely perceived as a “good backup for lower income communities,” Mehta told SNN — adding that possibly more low-income people need to go to these facilities.

“It’s safer. If you don’t have any help at home and without elevators, you will probably get better care,” Mehta said. “If you go home, it will be tough to move around without proper help. In certain neighborhoods, you don’t have easy walkways or a lot of things that come with where you live.”

In addition, researchers determined that where a patient obtains care and rehab after hip surgery does indeed impact the cost of hip replacement surgery. Metha referred to the what’s known as the cost of care, which is the total episode involving costs.

“So if a patient goes to rehab, it does cost more to the insurance company as opposed to the patient going home,” Metha said.

The overall research is still in early stages, Metha explained, adding that the team is “planning on taking a deeper dive in the future.”

The study was also conducted by the Said Ibrahim, senior investigator and chief of the Division of Healthcare Delivery Science and Innovation at Weill Cornell Medicine; Dr. Susan M. Goodman and Dr. Michael L. Parks of HSS; and Kaylee Ho of Weill Cornell Medicine.

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