What is discharge to Skilled Nursing Facility (SNF)?

From the Guidelines

Discharge to a Skilled Nursing Facility (SNF) is a transition of care from a hospital to a facility that provides 24-hour skilled nursing care, rehabilitation services, and other medical assistance to patients who no longer require intensive hospital care but still need professional help before returning home. This process typically occurs when a patient has completed their acute hospital stay and requires continued care to recover from their condition. According to the American Heart Association/American Stroke Association guidelines 1, SNFs provide "subacute" rehabilitation, which is less intensive than the care provided in inpatient rehabilitation facilities (IRFs) but still offers daily skilled nursing or rehabilitation services.

The decision to discharge a patient to an SNF is based on their individual needs, which are assessed by the hospital care team, including rehabilitation nursing case managers and social workers 1. Patients who are discharged to SNFs often have complex medical conditions, such as stroke or heart failure, and require ongoing care to manage their symptoms, prevent complications, and improve their functional abilities. The discharge process involves coordination between the hospital care team, the patient and family, and the receiving SNF, including transfer of medical records, medication reconciliation, and care plans.

Key characteristics of SNFs include:

• Provision of 24-hour skilled nursing care
• Rehabilitation therapies, such as physical, occupational, and speech therapy
• Medication management
• Wound care
• Assistance with activities of daily living
• Care provided under the direction of a physician, although daily supervision is not required

It is essential to note that SNFs are different from nursing homes, which provide long-term residential care for individuals who are unable to live in the community 1. While some patients may transition from an SNF to a nursing home, the primary goal of SNF care is to provide temporary, intensive rehabilitation and nursing services to help patients recover and return home. Medicare often covers SNF stays for eligible patients for up to 100 days, although full coverage is typically limited to the first 20 days, with co-payments required thereafter 1.

In terms of outcomes, patients discharged to SNFs are at high risk for rehospitalization and mortality, particularly those with heart failure 1. Therefore, it is crucial to carefully assess patients' needs and develop individualized care plans to ensure they receive the necessary support and services to achieve optimal outcomes. By prioritizing patient-centered care and coordinating transitions between care settings, healthcare providers can help improve morbidity, mortality, and quality of life for patients discharged to SNFs.

From the Research

Definition and Purpose of Discharge to Skilled Nursing Facility (SNF)

• Discharge to a Skilled Nursing Facility (SNF) refers to the transfer of a patient from a hospital or other healthcare facility to a SNF for further care and rehabilitation after an acute illness or injury 2, 3, 4, 5, 6.
• The primary goal of discharge to an SNF is to provide patients with the necessary medical care, therapy, and support to recover and regain their functional abilities, with the ultimate aim of returning home or to a lower level of care 3, 6.

Patient Outcomes and Readmission Rates

• Studies have shown that patients discharged to SNFs have a high risk of hospital readmission, with readmission rates ranging from 16.2% to 29% within 30 days of discharge from the SNF 2, 4, 6.
• Factors such as length of stay in the SNF, medical comorbidities, and prior use of healthcare services can increase the risk of readmission 4, 6.
• Patients with certain conditions, such as heart failure or cancer, may be at higher risk of readmission or mortality after discharge from an SNF 5, 6.

Rehabilitation and Functional Recovery

• Discharge to an SNF can be an effective way to provide patients with the rehabilitation and therapy they need to recover from an illness or injury, with some studies showing that patients can return to baseline independence after a stay in an SNF 3.
• The use of SNFs in conjunction with inpatient rehabilitation facilities (IRFs) may be an effective option for rehabilitation, allowing patients to receive the necessary care and support to return home 3.

Risk-Prediction Models and Interventions

• Risk-prediction models can be used to identify patients at high risk of readmission after discharge from an SNF, allowing for targeted interventions to reduce this risk 4.
• Interventions such as care management, home visits, and nursing phone calls may be effective in reducing readmission rates and improving patient outcomes after discharge from an SNF 2, 6.