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.

WWAMI Rural Health Research Center
Tracy Mroz, Lisa Garberson, Holly Andrilla, Susan Skillman, Eric Larson, Davis Patterson