Key result
SNF discharge is linked to ~8% lower 30-day primary care follow-up versus discharging directly home.
Why the study?
It was not known whether timely primary care follow-up after hospitalization differs for vulnerable populations, such as those with frailty or those discharged to skilled nursing facilities before returning home.
Does discharge to a skilled nursing facility or frailty reduce the likelihood of timely primary care follow-up after hospital discharge in Medicare beneficiaries?
Cohort (n=94,248,326)
Does discharge to a skilled nursing facility or frailty reduce the likelihood of timely primary care follow-up after hospital discharge in Medicare beneficiaries?
Effect estimate: difference -8.2 pp (95% CI -8.5 to -7.9)
Absolute Event Rate: 28.4% vs 57.5%
Frail patients and those requiring a short-term SNF stay after hospitalization are significantly less likely to receive timely primary care follow-up upon returning home.
SNF discharge flags risk for missed follow-up; hypothesis-generating for targeted transition interventions in frail Medicare patients.
BACKGROUND: Timely primary care follow-up after hospitalization is recommended to monitor recovery and coordinate care. Whether follow-up differs for vulnerable populations, such as those with frailty and those discharged to skilled nursing facilities (SNF) prior to returning home, is not known. METHODS: Retrospective cohort study using a 100% sample of traditional Medicare beneficiaries discharged from hospital to home or from hospital to SNF and then home, between 2010 and 2022. The primary outcome was the receipt of a primary care visit within 30 days of return to home, measured overall and stratified by disposition (discharged home vs. to SNF then home) and by frailty (defined by a claims-based frailty index). Multivariable logistic regression models were used to estimate changes in outcomes over time, overall and stratified by disposition and frailty. RESULTS: The cohort included 94,248,326 discharges (80.1% age ≥ 65 years, 55.1% female, 36.7% frail) of which 21.5% were discharged to SNF and then home. Between 2010 and 2022, primary care follow-up increased from 51.5% to 57.5% for patients discharged directly home and from 24.3% to 28.4% for patients discharged to SNF then home. In adjusted analyses, compared to those discharged directly home, patients discharged to SNF and then home had an 8.2% point (pp) (95% CI, -8.5 to -7.9) lower predicted probability of ambulatory follow-up in 2022. Among patients discharged directly home, no difference was evident in follow-up between frail and non-frail patients (54.6% vs. 54.1%); difference 0.4 pp (95% CI, -0.1 to 1.0). In contrast, among patients discharged to SNF then home, frail patients had a lower predicted probability of follow-up (42.8% vs. 48.9%); difference - 6.1 pp (95% CI, -7.0 to -5.2). CONCLUSIONS: Frail patients and patients requiring a short-term SNF stay after hospitalization are less likely to receive timely follow-up upon return to home than other patient groups.
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Anderson et al. (2025) conducted a cohort in Hospital discharge (n=94,248,326). Discharge to SNF then home vs. Discharge directly home was evaluated on Receipt of a primary care visit within 30 days of return to home (difference -8.2 pp, 95% CI -8.5 to -7.9). Patients discharged to a skilled nursing facility before returning home had an 8.2 percentage point lower probability of 30-day primary care follow-up compared to those discharged directly home.
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