Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey

Robert E. Burke, Jessica Phelan, Dori Cross, Rachel M. Werner, Julia Adler-Milstein

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Objectives: Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs. Design: Cross-sectional survey. Setting and Participants: A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF. Methods: We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics. Results: Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P = .049). Conclusions and Implications: These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes.

Original languageEnglish (US)
Pages (from-to)2565-2570.e4
JournalJournal of the American Medical Directors Association
Issue number12
Early online dateMay 29 2021
StatePublished - Dec 2021

Bibliographical note

Funding Information:
JA-M and JP were supported by a grant from The John A. Hartford Foundation (261408–5107206), which supported the development, administration, and analysis of the survey.

Publisher Copyright:
© 2021


  • Hospital
  • care transitions
  • integration
  • post-acute care
  • skilled nursing facility


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