The risk-standardised rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalisation. The prior proximal hospitalisation is defined as an admission to an IPPS, CAH, or a psychiatric hospital.

All unplanned hospital readmissions that arise from acute clinical events requiring rehospitalisation for any cause within 30 days of discharge from the patient's prior proximal hospitalisation. If a patient is readmitted more than once during the 30- day window only one readmission is included in the outcome

All SNF admissions within 1 day after discharge from the prior proximal hospital stay, and the SNF admission must occur within the target 12-month period used for SNFRM calculation.

SNF stays where the patient had one or more intervening post-acute care admissions (inpatient rehabilitation facility [IRF] or long-term care hospital [LTCH]) which occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge, within the 30-day risk window; SNF stays with no prior proximal hospitalisation, or SNF stays with a gap of greater than 1 day between discharge from the prior proximal hospitalisation and the SNF admission, or SNF stays with an admission date before the discharge date of the prior proximal hospitalisation; SNF stays where patients were not continuously enrolled in Medicare FFS for the year before prior proximal hospital discharge, the month of the prior proximal hospitalisation, and 1 month after the hospitalisation (measured as enrolment during the month of proximal hospital discharge, for 12 months prior to that discharge, and the month after the month of discharge); SNF stays where the patient was discharged from the SNF against medical advice; SNF stays in which the principal diagnosis for the prior proximal hospitalisation was for the medical treatment of cancer.

Risk adjusted for patient demographics, comorbidities, and other health status variables that affect the probability of a hospital readmission, including diagnoses of COVID-19.

Medicare FFS claims, Administrative Data (non-claims), Claims Data, Standardised Patient Assessments

Skilled Nursing Facility Value Based Program (CMS and Providers), linked to incentive payments based on performance. Not on CMS Care Compare.

Neuman MD, Wirtalla C, Werner RM. Association between skilled nursing facility quality indicators and hospital readmissions. JAMA. 2014 Oct 15;312(15):1542-51. doi: 10.1001/jama.2014.13513. PMID: 25321909; PMCID: PMC4203396. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/SNF-VBP/Measure www.acponline.org/clinical-information/performance-measures/skilled-nursing-facility-30-day-all-cause-readmission

www.cms.gov/files/document/2023-snfrm-measure-updates-report.pdf