Home Health Visits After SNF Stays Reduce Readmissions

After being discharged from a skilled nursing facility (SNF), patients who receive a home health visit immediately after returning home tend to have lower readmission rates, according to a recent study.

The study, “Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission,” found that a home health visit was the best way to reduce the likelihood of a readmission. Researchers from the Indiana University for Aging Research and the Regenstrief Institute looked at 1,500 “community-dwelling older adults” who were discharged from a SNF before they went home after a hospital visit.

In fact, a home health visit “immediately” after a discharge from a SNF was the factor “most significantly associated with lower readmission rates.” Starting in 2018, SNFs will be penalized for hospital readmissions for patients within the 30-day episode, in addition to the hospital.


And there are many patients who could benefit. One in five discharges of older adults look like this: patients are admitted the hospital, discharged to a SNF and then discharged home.

“We aren’t saying that seeing your physician after discharge form the SNF isn’t important,” Jennifer Carnahan, MD, MPH, IU Center for Aging Research and Regenstrief Institute investigator, said. “We are saying that having a home health worker visit as soon as you return home appears to be more significant in reducing hospital readmissions.”

Past studies have revealed that following up with a doctor upon returning home from a SNF can also be beneficial, but, at most, the results are equivocal, Carnahan noted. However, compared to a home health care visit, meeting with a physician is significantly more expensive and doesn’t have the same strong association with lower discharges.


SNFs typically arrange home health care visits prior to an older adult’s discharge to home, according to the study. Many home health care agencies find SNFs to be strong referral partners as a result of this relationship.

Authors of the study used the findings to promote greater access to home health care, urging policymakers to pay attention to ways to cut costs by keeping patients at home.

Written by Amy Baxter

Companies featured in this article: