Model Predicts Patient Risk of SNF Discharge on Day One of Hospital Stay

June 6, 2019

It is possible to accurately predict on the day of hospital admission whether a patient is likely to use skilled nursing facility (SNF) services, according to a study in the June issue of JAMDA.

In A “Hospital-Day-1” Model to Predict the Risk of Discharge to a Skilled Nursing Facility, the authors described obtaining data on 11,380 hospitalized patients to identify predictors of SNF discharge. They looked at socio-demographic variables including age, gender, marital status, insurer, day of admission, and location from which the patient was admitted; they then examined admission diagnoses (via individual diagnostic codes) and put these into clinically meaningful groups. They also looked at issues such as whether the patient lived alone, with family, or in a long-term (assisted) care facility and whether he or she could independently perform activities of daily living.

The final index included 11 variables. Using a model built around this index and these variables, the authors were able to predict with good accuracy on the first day in the hospital a patient’s risk of discharge to a SNF. They found that any impairment in mobility and/or bathing at hospital admission were among the most significant predictors of SNF discharge.

The authors observed, “Broad and early identification of patients likely to be discharged to SNF may be vital to clinicians, case managers, and hospitals seeking to improve care transitions.” They further suggested that “the successful identification of patients at risk for SNF discharge will require more than the evaluation of traditional administrative and clinical data but rather an assessment of the patients’ functional status, social support, and living situations as well.”

This study was conducted by researchers in the Division of General Internal Medicine, Department of Medicine, at Massachusetts General Hospital and Harvard Medical School, and in the Division of Hospital Medicine, Department of Medicine, University of California, San Francisco.

Click here for more information on the findings above and more details about the study. To contact the researchers or JAMDA editor for an interview, please email




JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit for more information.

About the Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit for more information.