Do Hospital-Based Skilled Nursing Facilities Provide Better Post-Acute Care Discharge Outcomes?

As hospitals are increasingly held accountable for patients' outcomes post-discharge under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) in order to better manage these outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. However, differential selection into hospital-based and freestanding SNFs can lead to biased estimates. By using "differential distance" to the nearest hospital with a SNF relative to the nearest hospital without a SNF, we mimic randomization of patients into more or less "exposure" to hospital-based SNFs when estimating the effects of hospital-based SNFs on discharge outcomes. Using national Minimum Data Set assessments linked with Medicare claims, we use a national cohort of residents who were newly admitted to SNFs from a hospital in 2009.  After instrumenting for hospital-based status, we found hospital-based and freestanding SNF patients spent relatively similar amounts of time in a health care institution and the community in the 180 days following their original hospital discharge. However, SNF patients in hospital-based facilities, on average, had more SNFs days, fewer hospital readmission days, and less home health care days. We did not observe a statistically significant impact on mortality.