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Predict Access to Skilled Nursing Facility

Readmitted patients are often clinically unstable at the time of transfer, AI ensures the transition to skilled nursing facilities goes smoothly.


Following a hospitalization, many patients require skilled post-acute care to support recovery, improve functional status, or manage chronic illness, and skilled nursing facilities (SNFs) are the most common setting for this critical care (1). More than five million patients are transferred from hospitals to SNFs annually (2), and in 2018, 20% of all hospitalized fee-for-service (FFS) Medicare beneficiaries were discharged to a SNF representing 2.2 million SNF stays (3). But despite the prevalence of SNF admissions, they frequently presage avoidable rehospitalizations and adverse events.

Size of the Problem

  • 20% of all Medicare beneficiaries were discharged to SNFs in 2018 (3).
  • 1 in 5 patients discharged to SNFs are readmitted within 30 days (4).
  • $563 million was the total amount CMS penalized hospitals in 2019 for excess readmissions (6).

Why it matters

The rate of 30-day readmissions to hospitals from SNFs is high. Close to one in five patients are rehospitalized within 30 days of transfer to a SNF, and a substantial percentage of patients are rehospitalized within just two days of initial SNF admission (4). Hospital readmissions following discharge to SNFs are also extremely costly. Total Medicare FFS spending on SNF services was $28.5 billion in 2018 (3), and hospital readmissions from SNFs have been directly attributed to more than four billion dollars (5).

However, studies have shown that hospital readmissions from SNFs disproportionately occur for preventable conditions. Readmitted patients are often clinically unstable at the time of transfer, and as many as two-thirds of these readmissions are estimated to be potentially avoidable (1).


AI can help healthcare organizations to accurately identify the patients most likely to be discharged to a SNF and ensure the transition goes smoothly—reducing hospital readmissions and improving health outcomes. With predictive analytics, organizations are able to proactively target high-risk patients with individually-tailored interventions before they are transferred to SNFs. These interventions can include intensive monitoring during the first 48 hours of SNF admission, specialist consultation follow-ups, and better pre-discharge evaluation of care needs (4).


  • Medical Claims: Data extracted from health insurance medical claims with details about dates and place of service, diagnosis codes, key procedures, use of medical equipment, and provider specialties.
  • Care Quality: Data with details from CMS Hospital Compare and other quality measures related to timely and effective care, complications, and readmissions and deaths.
  • Operations & Services: Data from health plans, clinics and service providers that capture details about service interactions, billing and payment, technical issues, and complaints.


  1. Neuman, Mark D et al. “Association between skilled nursing facility quality indicators and hospital readmissions.* JAMA vol. 312, no. 15, Oct. 2014, pp: 1542-1551. doi:10.1001/jama.2014.13513.
  2. King, Barbara ) et al. “The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study." Journal of the American Geriatrics Society, vol. 61, no. 7, Jul. 2013, pp: 1095-1102. DO: 10.1111/j95:12328.
  3. “Report to the Congress: Medicare Payment Policy” Medicare Payment Advisory Commission, Mar, 2020. Accessed on 12/8/2020.
  4. Ouslander, Joseph G., et al. “Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission.” Journal of the American Medical Directors Association, vol. 17, no. 9, Sept. 2016, pp. 839-845, doi:
  5. Mor, Vincent et al. “The revolving door of rehospitalization from skilled nursing facilities? Health affairs (Project Hope), vol. 29, no. 1, Jan.n 2010, pp: 57-64. doi:10.:1377/hlthaff.2009.0629.
  6. Rau, Jordan. “New Round of Medicare Readmission Penalties Hits 2,583 Hospitals.” Kaiser Health Network, Oct. 2019. Accessed 14 Dec. 2020.

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