The Crucial Role of Skilled Nursing Facilities in Reducing Hospital Readmissions

Hospital readmissions remain a critical challenge for health care facilities, particularly for patients discharged to skilled nursing facilities (SNFs) who later require an unplanned return to the hospital. These readmissions not only disrupt patient care continuity but also incur substantial costs, estimated in the billions annually, placing further strain on already tight health care budgets.

According to recent studies, approximately one in four Medicare patients discharged to an SNF is readmitted to the hospital within 30 days.

With Medicare's increasing penalties for excessive readmissions under the Hospital Readmission Reduction Program, understanding the role SNFs play in this equation is important. The relationship between hospitals and SNFs directly affects patient recovery and satisfaction, as well as hospitals' financial stability. For hospitals participating in value-based arrangements, such as accountable care organizations and other shared reimbursement programs, partnering with SNFs that can reliably prevent avoidable returns is central to both clinical outcomes and financial performance.

How Rehospitalizations Strain Care and Costs

Hospital readmissions are costly both financially and clinically. According to recent data from the Centers for Medicare & Medicaid Services (CMS), 21.0% of over 1.5 million discharges resulted in readmissions, and around 23.5% of patients discharged from acute-care hospitals to skilled nursing facilities experience rehospitalization within 30 days.

The average cost that occurs during this 30-day window is estimated at over $16,000 per patient. Combined, these readmissions result in approximately $4.34 billion in additional annual health care costs. What's more, an estimated 78% of these readmissions are considered potentially avoidable, representing an excess cost of over $3 billion to Medicare.

Beyond the financial burden, hospital readmissions compromise patient safety, increase the risk of medication errors, and result in decreased patient satisfaction. Frequent readmissions and multiple transitions of care increase the likelihood of negative health outcomes for patients, such as physical decline, medication complications, and cognitive issues like delirium.

What Factors Increase Hospital Readmission Rates

Skilled nursing facilities play a vital role in the patient care continuum, often serving as the next step after acute-care hospital stays. However, the transition from hospitals to SNFs can be fraught with challenges from several interconnected factors:

Staffing Levels and Quality

Staffing quality, particularly nursing staff ratios, directly influences patient outcomes. Facilities with lower staffing levels or inconsistent staffing have higher readmission rates. Studies show that facilities with higher nurse-to-patient ratios can significantly reduce readmissions and improve outcomes. For instance, an NIH-funded study in New York found that each additional patient assigned to a nurse raised readmission risk and that improved staffing could cut readmissions and length of stay. Broader reviews of nurse staffing trends also link higher staffing levels and better skill mix to fewer adverse events. Moreover, SNFs with higher staffing and CMS star ratings show lower readmission or mortality rates.

Patient Demographics and Clinical Complexity

Patients transferred from hospitals to SNFs frequently have multiple chronic conditions, complex medication regimens, and high care needs. Such complexities, combined with inadequate care coordination and discharge planning, increase readmission risk substantially. However, this can be successfully mitigated by the right strategic staffing plan.

Gaps in Communication and Care Coordination

Poor communication between hospitals and SNFs can lead to medication errors, incomplete treatment plans, and overlooked symptoms. Effective communication is critical for ensuring continuity of care, accurate medication reconciliation, and timely interventions that prevent deterioration or complications leading to rehospitalization.

Quality of Care

Facilities that perform well on standardized benchmarks, such as the CMS Five-Star Quality Rating System, tend to achieve better outcomes and lower readmission rates. Higher-rated facilities are more likely to have consistent staffing, effective protocols, and proactive interventions that improve patient outcomes. Additionally, hospitals that participate in value-based care and shared-savings programs, such as the SNF Value-Based Purchasing and Incite Workforce Solutions (IWS) Program, experience better care continuity and financial outcomes.

For example, Incite Workforce Solutions powered by SnapCare has demonstrated measurable improvements across multiple CMS quality benchmarks after clients adopted the IWS program. Facilities using the IWS platform consistently outperformed peers on key quality metrics, with most surpassing national performance standards. These improvements contributed to a nearly 5% reduction in readmission rates compared to the national average. Alongside these quality improvements, many clients also reduced reliance on contract full-time equivalents, lowered average labor costs, increased labor coverage, and strengthened staffing consistency. This led to lower staff turnover and up to a 50% decrease in regulatory fines.

The combined impact of a more stable workforce, tighter cost management, and greater care reliability has become the key driver in reducing readmissions and supporting the long-term success of IWS's value-based care initiatives.

How Do You Reduce Rehospitalization from SNFs?

Hospitals and SNFs can implement several evidence-based strategies to mitigate the likelihood of patient readmissions.

Establish Structured SNF Networks and Partnerships

Studies indicate that hospitals partnering with high-quality SNFs, defined by clear quality benchmarks and ongoing performance reviews, experience significant reductions in readmission rates. For example, care management and coordination strategies at Mount Sinai delivered a 20% drop in SNF readmissions. Similarly, long-term care partners in a Medicaid waiver program achieved a 7% reduction through navigator models and shared quality tools.

Collaborative relationships enable hospitals to align quality standards, improve communication, and ensure consistent patient care across settings. Preferred SNF networks also support shared savings goals by creating transparency, shared accountability, and more consistent performance under value-based contracts.

Improve Nurse Staffing Ratios and Training

Investing in adequate staffing, structured professional development, and comprehensive training programs can substantially improve the quality of care provided to patients. Facilities that maintain higher nurse-to-patient ratios and provide continuing education report fewer hospital readmissions and improved patient satisfaction scores.

Implement Predictive Analytics and Care Coordination Tools

Predictive analytics and integrated care coordination tools can identify patients at higher risk of rehospitalization and enable proactive management. Hospitals and SNFs that share access to electronic health records and streamline communication during transitions of care see measurable reductions in readmissions.

Additionally, SNFs using predictive staffing platforms, such as Booker powered by SnapCare, and facilities that implement automated care transition systems benefit from more efficient planning, reduced gaps in care, and better patient outcomes.

Provide Comprehensive Discharge and Transition Planning

Making sure patients and caregivers clearly understand post-discharge instructions, medication schedules, and follow-up appointments significantly decreases avoidable readmissions. Transition coaches or care coordinators also can help manage care transitions, educate patients, and ensure adherence to discharge plans. In fact, research shows that durable discharge practices can materially reduce returns within 30 days.

Engage Patients and Families in the Transition Process

Facilities that use patient-centered communication strategies-such as teach-back techniques-and actively involve patients and families in transition planning experience higher adherence to care plans and a reduction in preventable hospital readmissions. Empowering patients reduces anxiety, confusion, and adverse events related to care transitions.

Leverage Continuous Quality Improvement Programs

SNFs that participate in continuous quality improvement programs such as INTERACT (Interventions to Reduce Acute Care Transfers) experience reductions in hospital admissions. Such programs involve regular audits, performance monitoring, root-cause analyses of readmissions, and evidence-based interventions designed specifically to help SNFs sustain ongoing improvement. Hospitals can reinforce these efforts by aligning incentives through value-based purchasing and shared-savings models that reward measurable reductions in hospital readmissions.

Final Thoughts

Hospital readmissions from SNFs represent a costly and complex challenge; yet, they're largely preventable. Facilities that prioritize reducing readmissions benefit from lower penalties and greater alignment with value-based care goals. Studies have shown that implementing enhanced discharge planning protocols alone can yield a 15% reduction in readmissions, reinforcing the importance of proactive transition management.

Because of this, health care facilities and SNF providers must approach readmissions through a combined clinical and operational lens. Build preferred SNF networks based on measurable quality of care. Invest in staffing consistency and training. Standardize transitions with shared data access and predictive scheduling tools. Align incentives with value-based purchasing and shared-savings models so that hospitals and SNFs are rewarded for keeping patients well rather than simply moving them through the system.

Reducing readmissions leads not only to significant financial savings but also to better patient experiences, stronger care continuity, and overall improvement in community health outcomes.

To explore how Incite Workforce Solutions powered by SnapCare helps SNFs achieve better patient care outcomes and reduce hospital readmissions, visit our website and reach out to our team.