Skilled Nursing Facility Placement Process After Total Hip and Total Knee Arthroplasty: Revised Rating System and Opportunities for Intervention

Daniel J. Snyder, Thomas R. Kroshus, Aakash Keswani, Kevin J. Bozic, Yale A. Fillingham, Karl M. Koenig, David S. Jevsevar, Jashvant Poeran, Calin S. Moucha

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: With the advent of bundled payment models, identifying high-performing skilled nursing facilities (SNFs) has become increasingly important. The goal of this study is to develop a rating system to rank SNFs within our health system and to use this system to improve the SNF discharge process at our institution. Methods: All SNF-discharged primary total joint arthroplasty cases in 2017 at a multi-hospital academic health system were queried. Discharge patterns were assessed using heat map analysis. Regression analyses in conjunction with structured discussions with subject matter experts were used to identify measures of SNF efficiency and care quality. A revised rating system was developed and used to identify high-performing facilities within our health system. Opportunities to re-direct patients to higher performing facilities were identified. Results: A revised rating system for SNFs was constructed based on risk-adjusted SNF length of stay, 30-day re-admission rate, and 30-day emergency department visit rate. As 82% of patients were discharged to SNFs in close proximity to their home, high-performing SNFs (according to the revised rating system) were identified by geographic region. Mapping of the discharge process revealed multiple opportunities where patients could be re-directed to a higher performing SNF in their area. Using conservative estimates (25% of discharges re-directed), this is expected to achieve a cost saving of $2,600,000 over a 5-year period, mainly through reductions in SNF length of stay. Conclusion: This study describes the development of a revised rating system for SNFs which, when implemented, is expected to achieve substantial cost savings over a 5-year period.

Original languageEnglish
Pages (from-to)1066-1071
Number of pages6
JournalJournal of Arthroplasty
Issue number6
StatePublished - Jun 2019


  • episode-based outcomes
  • nursing home compare
  • post-acute care
  • rating systems
  • skilled nursing facility
  • total joint arthroplasty


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