Do I need to go to a skilled nursing facility? Hospital discharges to SNF during and after the COVID-19 pandemic

Abstract

Hospitalized patients who need rehabilitation or continued medical care are often discharged to skilled nursing facilities (SNF) for ongoing treatment. During the early years of the COVID-19 pandemic, overburdened hospitals were heavily strained, so the Centers for Medicare and Medicaid Services (CMS) waived its 3-day rule to obtain SNF care, effective March 1, 2020.¹ Patients no longer had to meet inpatient criteria or remain hospitalized for 3 days to transfer to SNFs. We sought to characterize trends in hospital discharges to SNF during the COVID-19 pandemic waiver.

As part of a discharge to SNF metric at an urban academic medical center, a database was created utilizing a retrospective cohort of Medicare beneficiaries who used hospital inpatient services, specifically examining those patients who were discharged to a SNF for additional care. Variables (age, concurrent depression diagnosis, length of stay, and ICU admission) were chosen to gauge severity of illness. Secondary data analysis was conducted, parsing the information into 3 years: March 2020–February 2021 (COVID Year 1), March 2021–February 2022 (Year 2), and March 2022–February 2023 (Year 3) and analyzed using univariate and chi-square analyses.

We examined 674 discharges to SNF across 607 individuals (Figure 1). Approximately 11% (n = 73) of discharges occurred in Year 1, 24% (n = 164) in Year 2, and 65% (n = 437) in Year 3. The mean preceding hospital stay in Years 1 and 2 was 12.0 versus 10.1 days in Year 3 (p < 0.05). In Year 1, no individual was held for fewer than 3 days before discharge to an SNF. Approximately 41% of discharges to SNF were preceded by an ICU stay in Year 1 versus 20% in Year 2 and 19% in Year 3, representing a significant decrease in the proportion of ICU stays between COVID Years (p < 0.0001). Mean age at discharge declined across years 1–3, from 84.84 in Y1, to 84.29 in Y2, to 83.54 in Yr3. The age decline between Years 2 and 3, from 84 in Year 2 to 79 in Year 3 was significant (p < 0.001). The proportion of patients discharged to SNF who had a depression diagnosis lessened significantly between years: 26% in Year 1 versus 12% in Year 2 versus 16% in Year 3 (p < 0.03).

This study is the first to examine hospital discharges to SNF over the three-year course of the COVID-19 pandemic. Hospital discharges to SNF were the lowest during the first year of the pandemic when severity of illness was the highest. Absence of a vaccine and facility visitor restrictions could have prompted patients and their families to choose discharge to home rather than SNF. Residents in long-term care facilities accounted for 37.7% of COVID-19 deaths in the United States by the end of 2020,² when the vaccine first became available. Visitor restrictions during the pandemic have been associated with increased emotional distress among patients and their families.³ These variables could explain why SNFs paradoxically had fewer admissions despite higher severity of illness.

As the pandemic receded and COVID-19 was less deadly due to the emergence of vaccinations, discharges to SNF increased while severity of illness decreased. Patients had shorter hospitalizations and fewer ICU stays. Mean age and proportion of patients with depression also declined. Waiver of CMS' 3-day rule could partially explain this finding. Patients hospitalized under observation status previously were not eligible for SNF admission. The waiver removed this barrier to entry.

These findings suggest that perhaps more older adult patients could have returned home instead of transferring to an SNF. During the pandemic, hospitalized older adults discharged with home health services had lower rates of 30-day rehospitalization than before.⁴ Patients who completed home health services had excellent symptom improvement and functional outcomes.⁵ Future research could investigate the factors that led to successful home discharge during the pandemic and whether they could be replicated now that it is over.

One limitation of this study is that it occurred at a single urban academic center. Results may not be generalizable to other settings. Other studies have observed a decline in SNF admissions during the first year of the pandemic,^{6, 7} thus corroborating some of our findings. In addition, more qualitative information would be helpful in determining how decisions on discharge location (SNF vs. home) were made.

Hospital discharges to SNF were the lowest during the first year of the COVID-19 pandemic and increased over time. Severity of illness decreased throughout the course of the pandemic. Our results pose the question whether, with proper support, more older adults could be discharged to home rather than SNF after hospitalization.

All authors met criteria for authorship by (1) providing substantial intellectual contribution to the study's conception and design (MT, AL, JW, LAL, VRZ.), data acquisition (MT, CO, LAL), data analysis (MT, CO, LAL), and interpretation (all authors); drafting the article or revising it critically for important intellectual content (all authors); and approving the final version to be published (all authors).

The authors declare no conflicts of interest.

The sponsor was not involved in the design, methods, analysis and interpretation of the data, and preparation of the manuscript.

This research is supported through grants from the NIH/NIA R01AG058777, R01AG068421, R01AG083034, and P30AG059988.