Hospital readmissions – when a recently discharged patient returns to the hospital – are a persistent challenge in healthcare. From a skilled nursing facility (SNF) perspective, rehospitalization refers to a resident being sent back to the hospital shortly after admission to the SNF. This problem is alarmingly common and costly. In fact, about one in five Medicare patients discharged from a hospital will go to a SNF for post-acute care, and nearly one-quarter of those SNF patients end up back in the hospital within 30 days! Such unplanned returns to acute care are not only expensive, but also dangerous – a rehospitalization is associated with a four-fold increase in mortality within six months for these patients. Given these stakes, regulators have zeroed in on readmissions as a key quality indicator. For SNF operators and hospital leaders alike, reducing avoidable rehospitalizations has become a top priority for improving patient outcomes and meeting performance benchmarks.
How is Rehospitalization Measured in SNFs and Hospitals?
Rehospitalization is typically measured as a 30-day readmission rate – the percentage of patients who return to a hospital within 30 days of a prior discharge or SNF admission. Both hospitals and SNFs track this closely. In the hospital setting, the clock starts at hospital discharge: if a patient is readmitted within 30 days (to any hospital) for an unplanned reason, it counts against the hospital’s readmission rate. In the SNF setting, CMS defines a similar measure: the “short-stay rehospitalization” rate, which looks at all new SNF admissions (or readmissions to SNF from a hospital) and checks if the resident had an unplanned hospital inpatient or observation stay within 30 days of entering the nursing home. Planned rehospitalizations (for example, a scheduled surgery) are excluded so that the focus is on potentially preventable returns.
Importantly, these readmission measures are risk-adjusted. Patients in SNFs often have multiple chronic conditions and significant frailty, which naturally increase their risk of hospitalization. The CMS measure for SNFs uses a risk adjustment model incorporating factors like the patient’s diagnoses, functional status, comorbidities, and other clinical variables from the Minimum Data Set (MDS) assessment. This helps to level the playing field, so facilities caring for sicker patients aren’t unfairly penalized. Similarly, hospital readmission metrics adjust for the mix of patients and conditions. Ultimately, whether in a hospital or SNF, a high 30-day readmission rate is a red flag – it signals that patients are cycling back into acute care when ideally their issues should have been managed without another hospitalization.
What Causes Rehospitalizations from SNFs?
Why do so many SNF residents land back in the hospital? The causes are usually a mix of clinical factors and system factors. On the clinical side, the typical SNF resident is an older adult with complex medical needs. Many are recovering from a serious illness or surgery and have multiple chronic conditions. Indeed, SNF patients are highly complex because of multiple comorbidities, frailty, and functional dependence, which predisposes them to complications. If underlying conditions flare up or new issues arise, a hospital transfer might be necessary. Research shows that infections and heart problems are among the most common culprits. For example, one large study of post-hospital SNF stays found that septicemia (bloodstream infection) was the single most frequent diagnosis for readmissions (accounting for ~17–22% of rehospitalizations), followed by other infection-related and circulatory conditions. Respiratory problems (like pneumonia or COPD exacerbations) and genitourinary issues (such as urinary tract infections) are also frequent triggers for a return to the hospital. It’s telling that the risk of readmission is highest in the first week or two after SNF admission, when patients are still in a fragile post-acute phase.
Beyond the diagnoses listed on the readmission charts, there are often deeper, systemic causes. High rehospitalization rates can indicate that a facility is struggling to manage certain aspects of care. For instance, a nursing home with frequent hospital transfers might be signaling that they struggle to effectively manage chronic conditions on-site, or that they are failing to prevent avoidable complications like infections and falls. Inadequate care coordination and communication issues can play a role as well. If a SNF doesn’t have a strong process for medication reconciliation, follow-up on test results, or physician evaluation of new symptoms, a resident’s condition might deteriorate until the only safe option is to send them to the ER. In some cases, insufficient staffing or resources in the SNF can limit the ability to deal with more acute changes in a resident’s condition. For example, if a resident develops shortness of breath or confusion, a well-prepared facility might initiate timely interventions (oxygen therapy, IV fluids, etc.), whereas an under-resourced facility may transfer the resident out immediately.
Certain patient demographics also face disproportionately higher risks of rehospitalization from SNFs. Research shows that residents with unstable housing histories or who are unhoused are significantly more likely to cycle back to the hospital. Factors like limited access to primary care, higher rates of untreated chronic illness, and social challenges such as lack of caregiver support or safe discharge environments compound medical fragility. These realities mean that for some populations, addressing rehospitalization requires not only strong clinical oversight within the SNF but also broader attention to social determinants of health that extend beyond the facility’s walls.
Patient and family preferences can factor in, too. Some families feel more comfortable with a hospital evaluation if anything goes awry, and some patients express a desire to return to the hospital when they feel very ill. However, experts estimate a significant portion of SNF-to-hospital transfers are potentially avoidable with better preventive care and early intervention. The bottom line is that while certain medical crises are unavoidable, many rehospitalizations stem from issues that could be addressed in the SNF setting if caught early and managed properly.
Impact on CMS Five-Star Ratings and Value-Based Penalties
Rehospitalizations don’t just harm patients – they also carry big consequences for healthcare providers. Both SNFs and hospitals are now judged and even paid based on their readmission performance. For SNFs, hospital transfer rates directly feed into the CMS Five-Star Quality Rating System. The Five-Star ratings (visible on Medicare’s Care Compare website) include a set of Quality Measures for short-stay patients, and one key metric is the “Percentage of short-stay residents who were rehospitalized after a nursing home admission.” A high rehospitalization percentage (remember, higher is worse for this measure) will drag down a facility’s Quality Measure score and thus its overall star rating. In practice, SNFs that successfully curb unnecessary hospitalizations see their quality ratings improve. As one industry expert notes, even a 10% reduction in hospitalizations can lead to a measurable uptick in a nursing home’s star rating. This makes sense – fewer readmissions signal that the facility is providing competent, proactive care, which is exactly what the quality ratings are meant to reflect.
Why do these ratings matter? A star rating isn’t just a vanity metric; it has real business implications for SNF operators. Consumers and hospital discharge planners pay attention to star ratings when choosing facilities. A lower star rating (which could result from high readmission rates) can hurt a SNF’s reputation, reduce referrals, and even impact occupancy rates. On the flip side, a strong 5-star rating can be a strategic asset, helping to attract more referrals and negotiate better contracts. In short, managing rehospitalizations well is part of maintaining a high-performing, marketable SNF.
Beyond ratings, there are direct financial penalties and incentives tied to SNF readmissions. The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program is a Medicare pay-for-performance initiative that withholds 2% of SNFs’ Medicare Part A payments and earns back some or all of that money based on the facility’s 30-day hospital readmission rate. SNFs are scored on either achievement (comparison to national benchmarks) or improvement (reduction in their own rate over time), whichever is better. In practice, this has meant real dollars at stake. When the program launched, it was reported that about three-quarters of SNFs ended up incurring a Medicare payment penalty in the first year (2019) – meaning they did not sufficiently beat the readmission benchmark to earn back their full 2%. While top-performing SNFs can earn bonus payments (up to a 2% increase in Medicare payments), those are relatively rare; most facilities are focused on avoiding the penalty. The VBP program underscores that reducing readmissions isn’t just good for patients – it’s increasingly tied to a facility’s bottom line.
Hospitals face their own share of pressure. Under Medicare’s Hospital Readmissions Reduction Program (HRRP), general acute-care hospitals are penalized if they have higher-than-expected readmission rates for certain conditions (like heart failure, heart attack, pneumonia, COPD, elective hip/knee replacements, and coronary bypass surgery). The penalty can be steep – up to 3% of a hospital’s total Medicare reimbursements. In recent years, the majority of eligible U.S. hospitals (roughly two-thirds) have been hit with HRRP penalties each cycle. In Fiscal Year 2022, for example, Medicare penalized 2,499 hospitals with an average payment cut of 0.64%, and 39 hospitals received the maximum 3% cut for that year. Over 10 years of this program, 93% of all eligible hospitals have been penalized at least once, which illustrates how pervasive the readmission issue has been. On a positive note, since these incentives kicked in, national readmission rates have modestly declined – experts attribute part of that improvement to hospitals and their partners (including SNFs) working harder on transitional care. Still, the penalties have collectively saved Medicare billions of dollars, and they’re not going away. Hospitals also have a star rating system for overall quality, in which the readmission domain is one factor, so excessive readmissions can indirectly tarnish a hospital’s public rating as well.
For SNF operators collaborating with hospitals under Accountable Care Organizations (ACOs) or bundled payment programs, there’s even more motivation to reduce rehospitalizations. In shared savings models, avoidable readmissions represent unnecessary costs that can prevent the network from hitting savings targets. Thus, both hospitals and SNFs have strong incentives – financial, regulatory, and reputational – to keep patients from bouncing back into hospital beds.
Early Signals and Strategies to Prevent Rehospitalization
Given the high stakes, what can be done to prevent rehospitalizations? Early identification of at-risk residents is key. Often, there are warning signs that a patient may be headed toward a health crisis if you know what to look for. Some risk factors are present from day one: for example, a predictive model developed at Mayo Clinic found that patients who had longer or more intensive hospital stays (especially involving ICU care), abnormal lab results, and a history of frequent hospital or ER use in the past 6 months were at higher risk of 30-day readmission after transfer to a SNF. Understanding these risk factors can help the SNF care team flag new admissions who might need extra vigilance and care planning (e.g. closer monitoring or a slower tapering of treatments).
Once the patient is in the SNF, frontline staff play a crucial role in catching early changes. Many SNFs have adopted the INTERACT (Interventions to Reduce Acute Care Transfers) program, which includes practical tools for early warning and intervention. A hallmark of INTERACT is the “Stop and Watch” early warning tool, a simple checklist that any staff member – not just nurses, but also nurse aides, therapists, even housekeeping – can use to note subtle changes in a resident’s condition. Stop and Watch prompts caregivers to notice things like: Is the resident eating or drinking less? Seeming more confused or lethargic? Having changes in skin or wound appearance? Reporting pain or not acting like themselves? These seemingly small cues, if communicated quickly to a nurse, can lead to a timely assessment and treatment tweak that prevents a hospital transfer. The idea is to catch a brewing problem (say, early signs of infection or a mild breathing difficulty) and manage it in-house before it becomes severe enough to warrant a 911 call.
In addition to staff vigilance, regular physician or advanced practitioner evaluation in the SNF can make a difference. Since many SNF residents are discharged “quicker and sicker” from hospitals nowadays, having clinicians in the facility who can promptly assess and treat changes (e.g. start IV antibiotics for a urinary infection or adjust diuretics for a heart failure patient) helps avoid sending the patient out. Some SNFs partner with telemedicine services or have nurse practitioners on-site to extend this capability during off-hours. Good communication with families is also important – aligning on care goals and educating them that not every fever or instance of confusion requires a hospitalization can reduce the knee-jerk reaction to send Mom back to the ER.
Lastly, quality improvement initiatives focused on transitions of care can dramatically cut readmissions. The INTERACT program itself demonstrated up to a 17–24% reduction in all-cause hospitalizations in nursing homes that diligently implemented its tools and protocols. Key strategies include thorough discharge planning from the hospital (ensuring the SNF gets a complete picture of the patient’s needs and pending tests), medication reconciliation to avoid errors, early follow-up by a physician, and engaging patients in their care plan. Many SNFs conduct root cause analyses after each rehospitalization to ask, “Could we have prevented this, and how?” This kind of learning culture helps identify system fixes, such as staff education on specific warning signs or setting up standing orders for common scenarios (like giving fluids for dehydration).
Conclusion
From a skilled nursing facility operator’s viewpoint, rehospitalization is a critical problem that sits at the intersection of patient care and organizational performance. It is measured closely by regulators, affects a facility’s star ratings and revenue, and most importantly, impacts the well-being of vulnerable residents. While some hospital transfers will always be necessary, a substantial portion can be avoided with the right approach. By understanding how readmissions are tracked and why they happen, healthcare teams can target the root causes – be it better chronic disease management, infection prevention, or communication gaps. Early warning systems and staff training to recognize a resident’s decline are proving their worth in heading off hospital trips. The incentives are aligned for both SNFs and hospitals to collaborate in these efforts: healthier patients who stay out of the hospital lead to higher quality ratings and fewer penalties under value-based models.
In summary, rehospitalization is a quality barometer for post-acute care. A low readmission rate signals that a SNF is succeeding in its role to rehabilitate and stabilize patients after a hospital stay. By focusing on early signals of decline, strengthening in-house clinical capabilities, and fostering a culture of continuous improvement, SNFs can keep residents on the right track – healing and gaining strength – instead of making a U-turn back to the hospital. Reducing rehospitalizations is not just a mandate from CMS; it’s core to delivering better care for patients and achieving the outcomes that patients, families, and healthcare providers all want to see.
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Sources:
- Burke RE et al., JAMA Network Open (2022) – Study on SNF VBP and readmissions (intro statistics: 1 in 5 SNF discharges; 25% 30-day readmissions; mortality impact) pmc.ncbi.nlm.nih.gov.
- CMS, Nursing Home Compare Technical Specs – Definition of short-stay rehospitalization measure (30-day unplanned hospital readmission from SNF) cms.gov.
- Riester et al., PLoS ONE (2022) – Causes and timing of 30-day rehospitalizations (common diagnoses like sepsis, heart failure; ~21–26% readmit rates for pneumonia/sepsis discharges; risk highest in first 2 weeks) journals.plos.org
- Chandra A. et al., J Am Med Dir Assoc (2019) – SNF readmission risk factors (18.2% readmission rate; risk model factors such as ICU stay, abnormal labs, prior utilization) pmc.ncbi.nlm.nih.gov.
- Quality Insights (2025) – CMS Five-Star rating insights (hospitalization rate as a key quality metric; reducing transfers improves star ratings) qualityinsights.org.
- Kaiser Family Foundation (2021) – HRRP 10-year results (Average 0.64% hospital penalty; 93% of hospitals penalized at least once; readmission rates declined under penalties) kff.org.
- Ouslander J. et al., Annals of LTC (2014) – INTERACT program overview (up to 24% reduction in hospitalizations with early warning & care pathways; “Stop and Watch” tool for early change in condition) pmc.ncbi.nlm.nih.gov.
