Research Alert: March 24, 2021

Post-acute Care Trajectories for Rural Medicare Beneficiaries: Planned versus Actual Hospital Discharges to Skilled Nursing Facilities and Home Health Agencies

Post-acute care services are designed to help patients transition from hospitalization in acute care facilities to their homes. Skilled nursing facilities and home health agencies provide the majority of post-acute care services to Medicare beneficiaries. This study used Medicare administrative data for rural, fee-for-service Medicare beneficiaries to describe post-acute care trajectories following acute hospitalization and examine differences between planned discharge disposition from the hospital and actual post-acute care received.

The majority (56.3%) of rural beneficiaries did not receive post-acute care following hospital discharge, while about a quarter (26.1%) experienced at least one care transition. Transition to skilled nursing facility (23.7%), transition to home health agency (18.2%), and transition to a skilled nursing facility followed by an additional transition to a home health agency (6.9%) were the most common trajectories among rural beneficiaries who received post-acute care. Gaps exist between planned and actual receipt of post-acute care as 88.9% of rural beneficiaries who had a planned discharged to a skilled nursing facility received this care and 58.7% of rural beneficiaries who had a planned discharge to a home health agency received this care. Identification of the reasons for the gaps between planned versus actual discharge to post-acute care and the outcomes for those who did not receive planned care will be critical for determining appropriate supports to improve care transitions for rural beneficiaries.

Contact Information:

Tracy Mroz, PhD
WWAMI Rural Health Research Center
Phone: 206.598.5396

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