Hospital to skilled nursing facility referral patterns are normalizing and admission numbers are recovering.
That’s according to a newly released report from WellSky, which also found that nursing homes have had to navigate fragmented care transitions more than ever, as real-time coordination continues to be a challenge despite digital advancements.
A lot of providers still operate in silos, and critical patient information is still getting lost or delayed as patients move between care settings, the report found. WellSky is a health care technology company serving more than 20,000 client sites across the care continuum.
Looking ahead, nursing homes need to be connected and proactive in this rapidly evolving care environment, WellSky reported, and that means having an approach that integrates data, people and processes across all care settings.
Gaps in care transition
When it comes to rising referral volume and patient acuity, WellSky points to an overwhelming combination of people living longer and having more complex medical and behavioral health needs that require individualized care pathways.
Between 2019 and 2025, the average inpatient hospital discharge post-acute care referral acceptance rate never climbed above 37%, falling to its lowest in 2022 at 23.6%. The number of inpatient hospital discharge post-acute care referrals reached 56,000 in 2025, compared to 24,000 referrals in 2019.
WellSky found that as patient needs grew more complex and capacity remained constrained in nursing homes, securing a post-acute care placement required more referrals sent per patient. Providers submitted an average of 6.6 referrals per patient in 2024, with an average of 32% of all submitted referrals resulting in an acceptance.
Recent data from WellSky shows SNF referrals have stabilized, meaning hospitals are sending about the same number of patients to SNFs as they did in 2024. However, the number of patients accepted and then admitted to a SNF increased significantly, nearly 43% since 2019 and 8% in 2024 alone.
“This suggests that, after several years of fluctuation during the pandemic, referral patterns are leveling off while admission rates are rebounding, pointing to a normalization of SNF utilization,” WellSky reported.
Patient acuity has increased by 34% since 2019, according to the Van Walraven Index, along with a steady rise in comorbidity; the average number of Elixhauser conditions – an index of comorbidities – per patient grew from 3.4 to 4.96 between 2019 and 2024.
Chronic and complex conditions are popping up more frequently, including renal failure, pulmonary circulation disorders and obesity. Behavioral health challenges in particular are intensifying as long wait times, fragmented access and a significant increase in drug and alcohol use among post-acute patients combine and complicate care.
Communities of color, rural residents and people with limited resources continue to face substantial barriers to culturally responsive, integrated behavioral health and addiction care, according to Wellsky.
But while referral patterns may be normalizing, barriers to effective care transitions remain, as the WellSky report cited several studies illustrating this point. Only 55% of hospitals can electronically find, send, receive and integrate patient information from outside organizations like a nursing home – leaving nearly half without a reliable foundation for seamless care coordination, according to a 2024 Office of the National Coordinator for Health Information Technology (ONC) report.
About 56% of health care leaders said care transition fragmentation was the top barrier to effective care transitions, according to a survey conducted by the New England Journal of Medicine (NEJM), while 41% said poor communication between providers was the top barrier.
Care transition barriers translate to an estimated $30 billion to $90 billion in avoidable annual costs, according to a report in Health Affairs, as clinicians deal with avoidable hospitalizations, preventable complications and inefficient transitions between sites of care.
AI eases staff burdens, VBC forecast
The evolution of care in 2025 has also been characterized by continued staffing shortages – it’s a constant pressure operators have dealt with for years, to do more with less.
About 90% of health care workers told WellSky that care coordination tools are helpful for improving efficiency and care delivery, and 89% said electronic health records prove valuable. About 69% of nurses said AI is helpful in day-to-day operations.
The fourth edition of the report also found that AI and predictive analytics help providers deliver smarter, more efficient care while also making better use of staff and resources. New regulations were mentioned as well, specifically concerning value-based care.
Models like the Transforming Episode Accountability Model (TEAM) reflect the Centers for Medicare and Medicaid Services’ (CMS) commitment to advancing coordinated, risk-based care, WellSky reported.
The new mandatory bundled payment model set to launch Jan. 1 is a continued push toward episode-based reimbursement, and will require greater collaboration among hospitals and post-acute care partners,along with improved discharge planning and robust data tracking to take advantage of new financial incentives, according to the WellSky report.
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