Motivating and Enabling Factors Supporting Targeted Improvements to Hospital-SNF Transitions

ABSTRACT

Objectives: Older adults with Alzheimer disease and related dementias (ADRD) experience hospital-to-skilled-nursing-facility (SNF) transitions at disproportionate rates, yet it is unclear whether investments in information sharing practices are equitably distributed across SNFs that care for more of these patients. The purpose of this study was to characterize and compare hospital-SNF dyads according to the proportion of patients they share who have diagnosed ADRD and to analyze whether specific motivating (ie, historical readmission rates) and/or enabling (ie, health information exchange [HIE], informal integration) factors are associated with higher-quality information sharing practices relative to the concentration of patients with ADRD.

Study Design: Cross-sectional study linking pooled Medicare claims data (2016-2019) to a nationally representative survey (2019-2020) that collected detailed information on how hospitals share information to support postacute care transitions with SNF partners.

Methods: Multivariate linear regression.

Results: Hospital-SNF dyads sharing a high volume of patients with ADRD report information received during transfer to be of similar quality (ie, information is timely, complete, and usable) to low-ADRD dyads, although capacity for HIE still lags. Overall, hospital-SNF dyads that combined informal integration efforts with HIE capabilities fared better with respect to the quality of information shared.

Conclusions: SNFs experiencing high-ADRD referral flows may be working harder than most to manage transitional care without similar availability of resources that enable high-quality handoffs. Policy makers should consider systematic investments in postacute care data sharing standards and payment models that incentivize informal integration efforts to enhance the value of investments in information technology–supported information continuity.

Am J Manag Care. 2026;32(1):In Press

Takeaway Points

This study examined the quality of information sharing practices to support transitions of care at the level of the hospital–skilled nursing facility (SNF) dyad and in terms of the shared volume of patients with Alzheimer disease and related dementias (ADRD).

• SNFs experiencing high-ADRD referral flows report lower capacity for electronic information exchange (eg, shared electronic health record, view-only portal access).
• Hospital-SNF dyads with both health information exchange capabilities and evidence of informal integration (eg, shared protocols, staff) receive higher-quality information (ie, information that is timely, usable, and complete).
• Incentivizing tailored informal integration activities may enhance the value of investments made in information technology capabilities to support transitions of care.

Skilled nursing facilities (SNFs) are critical institutions in the continuum of long-term and postacute care services. In Medicare fee-for-service alone, nearly 5000 hospital discharge referrals every day (1.8 million referrals annually) send beneficiaries to a SNF.1 This transition disproportionately involves patients with Alzheimer disease and related dementias (ADRD).2 However, there is significant concern that placement decisions and transitional care practices3 do not accommodate the specific needs of the growing population with ADRD.4 Specifically, deficits in the timeliness, completeness, and usability of information shared by the hospital may prevent SNF staff from maintaining continuity in both clinical and comfort aspects of care, leading to care interactions that are especially challenging for patients with cognitive concerns. This becomes especially relevant when cognitive impairment interferes with a patient’s ability to narrate or fill in the gaps left by incomplete or missing information.5,6

The extent to which specific transitional care needs of patients with ADRD are overlooked may be compounded as hospitals look to systematize practices with their SNF partners. Hospitals tend to concentrate care investments within a preferred network of high-volume SNF partners, but patients with ADRD are less likely to be placed at these preferred care sites.7 This may mean that hospital-SNF partnerships serving more patients with ADRD (ie, high-ADRD dyads) are less equipped with enabling resources to identify and address information deficits in transitional care practices. These include, for example, the extent of informal integration activities happening between a hospital and a SNF. Activities such as joint leadership meetings or shared clinical staff that span the 2 organizations can help hospitals build knowledge of the SNF environment and the informational needs of SNF staff.8-10 Availability of electronic health information exchange (HIE) is another enabling tool that hospitals have used to strengthen care partnerships with SNFs through improved accessibility of information.11 However, interoperability across postacute care settings and hospital providers remains subpar.12 If SNFs receiving a sufficiently high volume of patients with ADRD from their hospital referral partners differ in their access to informal integration activities and/or HIE capabilities, this may not only impede progress for improved care transitions in these dyads but also raise concerns that investments concentrated in care settings with fewer patients with ADRD may lead to greater disparities for these patients.

Yet it is also possible that high-ADRD dyads are more motivated than the average hospital-SNF partnership to address issues of poor information sharing. The literature on the benefits of service specialization—in the postacute care context and more broadly—suggests that hospital-SNF dyads that care for many patients with ADRD may be better able to both recognize and advocate to address the specific challenges caused by poor information sharing with respect to this population, given the concentration of patients they see with this specific set of care needs.4,9,13-15 Patients with ADRD are also more likely to be readmitted to the hospital,16,17 so a high concentration of these patients cycling between the hospital and SNF could help trigger a focused discussion on process improvements that address the needs of these patients. Hospitals may be more amenable to conversations with these facilities to the extent that high-ADRD facilities represent a distinct form of preferred partner status—not for their overall high volume, but as reliable partners to which a hospital can refer patients with cognitive care considerations or who are more complex overall for more specialized attention.

As hospitals invest in information sharing practices, it is unclear whether patients with ADRD and the facilities that disproportionately serve these patients benefit from these improvements. We combined patient-level Medicare claims data with national SNF survey data designed to elicit information about the quality of information sharing practices with hospital partners. This point-in-time survey was designed to characterize information exchange capabilities across diverse hospital-SNF partnerships, with the goal of understanding whether more differentiated approaches might be needed to motivate HIE investment. We sought to analyze whether specific factors hypothesized to strengthen information sharing practices are associated with higher reported information quality and whether this relationship is consistent across organizations serving many vs few patients with ADRD. The difficult work of achieving high-quality transitions requires iterative reflection on how well clinicians and administrators think transitional care is working, examining both the enabling structural factors that support the process of information sharing (ie, HIE, informal integration) and motivating feedback signals from the outcomes sensitive to these processes (ie, readmissions). Given the cross-sectional nature of the survey, we were unable to establish any causal direction, so we focused on establishing associations that deepen our understanding of how organizations serving different population needs are pursuing transitional care work. These findings are important for shaping policy and administrative practices that support organizational improvement inclusive of the needs of patients with ADRD and those with other complex medical and social needs.

METHODS

Data and Sample

We used data from a nationally representative survey that collected detailed information on how hospitals share information to support postacute care transitions with SNF partners. The survey was sent to 500 SNF directors of nursing between January 2019 and March 2020. Additional details about survey development and administration can be found elsewhere.8,18 SNFs were asked to detail their relationship with each of their 2 highest-referring hospital partners based on shared patient volumes identified through traditional (ie, fee-for-service) Medicare claims data. Questions included detailed information sharing practices by each hospital with respect to what information is shared (completeness), when it was shared (timeliness), and how it was shared (usability). We merged these data with pooled patient-level data from a 100% sample of 2016-2019 Medicare Provider Analysis and Review (MedPAR) records. MedPAR contains information on hospital and any subsequent SNF admissions for traditional Medicare beneficiaries. This data source allows us to attribute individual patients—both their identifying clinical characteristics and the subsequent outcomes of their hospital-to-SNF transition (eg, incidence of readmission)—to a specific hospital-SNF pair or dyad. Hospital and SNF organizational details were supplemented with information from Medicare public use files.

Outcomes

Outcomes of interest reflect the quality of information sharing practices within a hospital-SNF dyad, measured along 3 dimensions: completeness, timeliness, and usability. Completeness was assessed using an index score, with 1 point each for regular availability of 24 specified data elements (eg, reason for inpatient admission, current medications, pending laboratory tests) available at the time of patient transition from the hospital, including specific information on social, mental, behavioral, and functional status (eAppendix Table 1 [eAppendix available at ajmc.com]). Because of the nonnormal distribution of this measure, we operationalized this as a binary indicator for high completeness, specifically, whether an SNF regularly received at least 80% (approximately) of data elements (≥ 20 of 24 elements), reflective of the modal point of our data.8,18 Timeliness was assessed using a 5-point perception scale, with respondents asked to respond to the following prompt: “Information is provided in a timely manner to support decision-making.” We created a binary indicator for whether the SNF ranked their hospital partner as a 4 or 5, with 5 representing excellent timeliness. Finally, usability was captured through 8 measures, including consistency in how the discharge summary was presented with respect to labeling, highlighting, ordering, colocation of relevant information, format for printing, lack of duplication, lack of extraneous information, and/or tailoring of information specific to the SNF context. Hospitals with 5 or more of these 8 practices in place were considered to share highly usable information.

Predictors

Enabler(s) of information sharing. Our first measure of enabled information sharing was the extent of informal integration activities happening between a hospital and an SNF, which may improve shared understanding of what information is needed to support successful transition.8,10,19 Hospital-SNF dyads received an index score out of 8, with a point assigned for the presence of each of the following informal integration activities: shared care protocols, clinicians, care coordinators/case managers, quality improvement initiatives, processes for improving medication safety, or rehospitalization/ED visit avoidance, and/or joint leadership meetings or shared transitional care tools. We then created a binary indicator for high informal integration if a hospital-SNF dyad reported 4 or more informal integration activities.

Our second measure of enabled information sharing was access to electronic HIE, which may facilitate the identification of or systematic improvements to our key outcome measures, including the completeness, timeliness, and usability of information sharing processes.9,10,17 We included a binary indicator for whether an SNF had electronic access to their hospital partner’s electronic health record (EHR), either through view-only portal access or through shared systems.

Motivators of information sharing. One key motivator of targeted improvements in information sharing practices is a historical challenge regarding high rates of hospital readmission. We used 4 years of MedPAR data both prior to (2016-2018) and concurrent with (2019) the year of survey administration to calculate dyad-specific, unadjusted 30-day readmission rates.

SNF organizational characteristics. We included as additional covariates several organizational characteristics known to be associated with SNF resources and capacity for process improvements and optimization. This includes SNF size, ownership, rurality, quality rating based on Nursing Home Compare data, and the percentage of patients dually eligible for Medicare and Medicaid.20-26 We also included an indicator for whether the SNF had a designated Alzheimer unit, a structural characteristic that may indicate ability to provide specialized care to patients with more advanced stages of ADRD.

Analytic Approach

We first calculated the percentage of patients within each observed hospital-SNF dyad with an ADRD diagnosis and specified a data-driven cut point for low- vs high-ADRD dyads. High-ADRD dyads reflect hospital-SNF pairs that care for the top 50th percentile of ADRD patient volume, calculated as the proportion of total shared patient volume, averaged over a 4-year period. We generated summary statistics that (1) described our sample according to characteristics of the dyad and of the organizational members of that dyad (hospital vs SNF) and (2) compared low-ADRD dyads with high-ADRD dyads. This included differences with respect to our enabling and motivating characteristics as well as our outcome variables (ie, measures of information sharing quality).

Next, we used multivariate regression to predict information sharing enhancements as a function of whether a hospital-SNF dyad exhibited enabling factors (HIE and/or shared informal integration activities) and/or motivating factors (high historical 30-day readmission rates) to address challenges related to information sharing quality. We ran both unstratified models and models stratified by shared ADRD volume and included clustered SEs by SNF identifier to account for repeat observations. We reported results using predicted probabilities to visualize differences in tested associations for low- vs high-ADRD dyads.

Finally, we were interested in whether our results were sensitive to where we drew the cut point for high-ADRD dyads. We used a top 50% cut point for our primary analyses; supplemental results with a more stringent top 25% cut point are provided in the eAppendix. We also offered an alternative motivating factor, substituting historical 7-day readmission rate for 30-day readmission rate.27,28

RESULTS

Survey responses contained data on 265 SNFs (53% response rate; respondents similar to nonrespondents).8,10 We retained 215 SNFs and 403 hospital-SNF dyads with sufficient data for this analysis (81% of SNF survey respondents). Of the 403 hospital-SNF dyads analyzed, we defined the top 50% of dyads in terms of shared ADRD population as high-ADRD dyads (n = 201); this translated to a cut point (4-year mean of shared patients with ADRD) of 14.7% or greater. In sensitivity analyses, the top 25% cut point (n = 100) was designated at 17.4% or greater. The complete distribution of the percentage of shared patients with ADRD is shown in the eAppendix Figure.

We observed significant organizational differences between high-ADRD (top 50% of ADRD volume) and low-ADRD dyads (Table). High-ADRD dyads were more likely to be for-profit (76.6% vs 60.9%; P = .001) and to care for more dually eligible patients (40.4% vs 28.9%; P < .001) than low-ADRD dyads. We also observed significant differences in quality rating and SNF size, with high-ADRD dyads less likely to include SNFs that are small (20.4% vs 30.7%; P = .029) and rated 4 or 5 stars overall based on CMS Star Ratings (44.3% vs 59.4%; P = .002). We did not observe differences with respect to rurality or presence of a dedicated Alzheimer unit, nor did we observe any significant unadjusted differences with respect to SNF-reported completeness, timeliness, or usability of information by shared ADRD volume.

With respect to enabling and motivating factors (Table), slightly more than half (56.3%) of all dyads had some HIE capacity, with more low-ADRD dyads reporting enabling HIE capacity (61.4% vs 51.2%; P = .040), and roughly equal proportions reporting high informal integration. Overall dyadic unadjusted 30-day readmission rates were 18.3% in low-ADRD dyads compared with 20.1% in high-ADRD dyads (P = .008), with no significant difference in ADRD-specific readmission rates between dyads.

Predicting Information Sharing Quality: Completeness

In fully adjusted regression models (eAppendix Table 2), we found that neither HIE capability nor informal integration efforts were significantly associated with a higher probability of data completeness for low- or high-ADRD dyads. Similarly, historical 30-day readmission rates had no significant effect on data completeness in either group.

Predicting Information Sharing Quality: Timeliness

Enabling factors. Among all 403 dyads, having either integration only (n = 30), HIE only (n = 134), or both (n = 87) was significantly associated with greater information timeliness compared with none of these factors being present (Figure 1). In stratified analyses, evidence of informal integration was positively and significantly associated with timeliness in both low- and high-ADRD dyads. HIE was also predictive of greater timeliness, although only independently predictive among high-ADRD dyads. In low-ADRD dyads, HIE was only positively associated with timeliness when informal integration was also present.

Motivating factors. Among all dyads, high historical readmission rates (> 16.6%; tertiles 2 and 3) were significantly and negatively predictive of receiving timely information (Figure 2). We observed no association between historical readmission rates and timely information sharing in low-ADRD dyads. For high-ADRD dyads, high historical 30-day readmission rates were significantly and negatively associated with receiving timely information (54.8% were likely to report timely information sharing in the highest tertile vs 77.3% in the lowest tertile; P = .030).

Predicting Information Sharing Quality: Usability

Enabling factors. For all dyads, presence of both HIE and high levels of observed informal integration activities resulted in a significant increase in the predicted probability of receiving usable information compared with having neither HIE nor informal integration (51.2% vs 29.0%; P = .006) (Figure 3). Availability of HIE alone or informal integration activities alone was not associated with any meaningful difference in information usability. These findings were consistent in stratified analyses separately examining low-ADRD and high-ADRD dyads.

Motivating factors. Unstratified models show a clear, although largely nonsignificant, trend in high historical readmission rates and efforts to improve information usability; dyads with high historical readmission rates had a 44.7% predicted probability of high usability (P = .038). For low-ADRD dyads, our results showed a clear association between high historical readmission rates and efforts to improve information usability. Low-ADRD dyads in the highest tertile with respect to historical readmission rates had a 46.5% predicted probability of high usability compared with only 22.8% in the lowest tertile (P = .020). We did not find historical readmission rates to be associated with information usability for high-ADRD dyads (Figure 4).

Sensitivity Analyses

We tested 2 alternative model specifications. First, we substituted historical 7-day readmission rates as a motivating factor that may be associated with information quality. Results were largely consistent with our primary analyses. We next examined a more restrictive definition of high- vs low-ADRD dyads. Specifically, we tested an alternative cut point based on the top 25% of shared volume (≥ 17.4%). Results were again directionally consistent with primary analyses, although we observed some loss of statistical significance among high-ADRD dyads due to lower sample size (101 high-ADRD dyads vs 302 low-ADRD dyads). We also found some additional evidence to suggest that historical 30-day readmission rates were associated with information completeness (52.0% [tertile 3] vs 23.6% [tertile 1]; P = .074) for high- but not low-ADRD dyads (eAppendix Table 3).

DISCUSSION

Using a 4-year, 100% sample of MedPAR encounter data linked with nationally representative survey data describing hospital-SNF information sharing practices, we examined whether the timeliness, usability, and completeness of information to support transitions of care across high- and low-ADRD dyads were predicted by key enabling and motivating factors. Unadjusted comparisons suggested no difference in reported information quality based on ADRD concentration, despite the fact that high-ADRD SNFs were more likely to be for-profit, have a lower CMS Star Rating, and serve a greater percentage of dually eligible patients. These characteristics have been associated with less investment in quality improvement practices due to lack of prioritization and/or capacity.20,22-24,29 We also found that when enabling factors were in place—HIE combined with informal integration practices—low- and high-ADRD dyads experienced similar predicted levels of more timely and usable, but not necessarily more complete, information sharing. However, reported capacity for HIE (eg, shared EHR, view-only portal access) lagged in SNFs that care for the highest volume of patients with ADRD. Taken together, these results suggest that hospitals’ information technology (IT) investments are not responsive to differences in the clinical profile of patients shared across different SNF partners and that those experiencing high-ADRD referral flows may be working harder than most to manage transitional care without the same enabling resources.

Interestingly, historical readmission rates (7- and 30-day) were found to have a significant association with information usability in low-ADRD but not high-ADRD dyads. Although important to supporting efficient transitions, information usability is arguably the least important outcome. Improving the usability of information shared with SNF partners to support transitions of care largely reflects changes in how default or existing information is presented—for example, reordering information such that the most pertinent information is presented first, labeled appropriately, and highlighted—and does not require hospital partners to adopt process improvements that address root causes, such as limited or absent coordinating behaviors or information deficits that contribute to delays or incomplete care. Hospitals are still largely responsible for what, how, and when information is shared with SNFs. Thus, an association between historical readmission rates and information continuity is perhaps conditional on whether hospital partners identify this metric as a shared problem worthy of targeted quality improvement investments.6

Existing research has found that observable improvements to quality of care are realized when almost all (> 90%) of the facility’s admissions are patients with ADRD,4 but this degree of hyperspecialization comes with limitations (eg, difficult to staff, harder to cross-subsidize on payer mix) that make this organizational pathway an unlikely solution. Yet, hospitals maintain different types of specialized relationships with their partners. Although volume-based relationships are one route, investing in those partners that accept placement of the most clinically and social complex patients—irrespective of volume—might also be worth strategic consideration.7,9,30 If what our evidence suggests mirrors operational relationships, it is problematic that dyads that manage and share a high volume of referrals for patients with ADRD—although not lagging behind in the quality of information sharing practices—are not receiving any observable specialized investments. Thus, future research examining opportunities to improve information sharing practices in this context may hold particularly high value.

Limitations

Our study had several limitations. First, the survey on which our analyses relied solicited responses from SNFs with respect to their 2 highest-volume hospital partners, from which we can presume there is more familiarity with basic admission processes. As a result, we likely underestimated the true scope of information deficits when it comes to planning for transitions across hospital and SNF partners. Second, this was a cross-sectional, point-in-time study, which precluded us from drawing any conclusions with respect to the causal direction of quality improvement processes. Further quasi-experimental data will be important in teasing out predictors of longitudinal improvements to information quality. Lastly, we relied on claims-based diagnoses of ADRD. Future research should consider alternative diagnostic records, such as assessment data or clinical encounter data, to construct a more nuanced definition of cognitive impairment or ADRD.

CONCLUSIONS

Organizations that treat many patients with ADRD do not seem to lag in electronic information sharing capabilities, although overall quality of information sharing to support transitional care remains suboptimal. Investments in HIE capabilities alone are not enough to improve information sharing practices but may offer some enhancements in combination with a high level of informal integration activities that presumably help shape impactful HIE use. As the complexity of the postacute care SNF population continues to rise, policy makers should consider systematic investments in postacute care data sharing standards with respect to timeliness, completeness, and usability to enhance the value of investments in IT-supported information continuity as well as reimbursement or practice models that support investments in partnerships that serve an increasing number of medically and socially complex individuals.

Author Affiliations: Department of Population Health, University of Kansas School of Medicine (TIB), Kansas City, KS; Department of Health Administration, Virginia Commonwealth University College of Health Professions (JPM), Richmond, VA; Division of Health Policy and Management, University of Minnesota School of Public Health (DAC), Minneapolis, MN.

Source of Funding: This work was funded by the National Institute on Aging (5R03AG072215) and the Agency for Healthcare Research and Quality (R36HS029644).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TIB, JPM, DAC); acquisition of data (TIB, JPM, DAC); analysis and interpretation of data (TIB, JPM, DAC); drafting of the manuscript (TIB, JPM, DAC); critical revision of the manuscript for important intellectual content (TIB, JPM, DAC); statistical analysis (TIB); obtaining funding (JPM, DAC); and supervision (TIB, JPM, DAC).

Address Correspondence to: Taylor I. Bucy, PhD, University of Kansas School of Medicine, 3901 Rainbow Blvd, Mail Stop 1008, Kansas City, KS 66160. Email: tbucy@kumc.edu.

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