There’s No Place Like Home

SNF Readmission and Mortality Risk Versus Discharges to Home

Co-Authored by Steve Wiggins, Brittain Brantley, Mary Dittrich, MD, Marina Burke, NP, Win Whitcomb, MD

Evidence is growing that patients fare comparatively well when choosing to go home after a hospitalization, versus being admitted to a post acute facility. Patients discharged to their homes have readmission and mortality risk that is equivalent and possibly lower than patients with similar conditions who are discharged to SNFs or other post acute facilities. Remedy’s own research, as well as studies published by the American Heart Association and the American Journal of Medicine, provides encouraging evidence to support discharges to home for challenging patients.

Remedy’s clinical and analytics team recently finalized a 1,537 patient study of our Care At the Right Location (CARL) tool. The study sought to validate the CARL assessment for deployment across all of our Episode Initiators and to identify the primary variables (questions) that predict patient outcomes. The CARL assessment tool has been developed by Remedy’s clinical team to provide decision support for Case Managers and Physicians when discharging patients from hospitals.

Remedy’s study of the CARL tool reviewed records of 1,537 patients who completed an Episode of Care in the BPCI program.  A risk adjustment index was calculated for each patient, which is an analytic technique that attempts to adjust for a wide range of patient characteristics known to be associated with adverse outcomes, regardless of where patients were discharged (Post Acute Facility, Home or Home with HHA services). A risk-adjusted comparative analysis creates more reliable inferences between post-acute environments. Characteristics of the Remedy model included patient demographics and comorbidity index adjustment (Elixhauser method).

CARL Results

The CARL Assessment Module, that is being rolled-out to all Remedy programs next week through Episode Connect, delivered solid and promising results.

  • Use of the CARL tool should lower post acute costs by over 16 %.
  • The CARL Tool will shift approximately 17% of discharged patients from post acute facilities (SNF/IRF/LTACH) to home with home health agency services.
  • The risk adjusted readmission rates are largely the same, regardless of whether patients with similar conditions are discharged to home, home with home health, or to a post acute facility.
  • Remedy did not measure mortality rates, although the American Heart Association study suggests the risk-adjusted mortality rates in SNFs are higher than for HF patients discharged to the home.

Discharge Location Comparison

Pac Facility 34% 17% 33.3%
Home w/ HHA 15% 32% 33.1%
Home 51% 51% 32.4%

Peer-Reviewed Research Results

A small number of peer-reviewed studies compare outcomes for patients discharged to home to patients discharged to post acute facilities. The American Heart Association study of 15,429 heart failure patients reported compelling results. After adjustment for measured patient characteristics, this study reported that discharges to SNF were associated with increased death and re-hospitalization.  The study stated:  “compared with similar patients discharged to home, discharge to SNF is associated with a 76% increased risk of death after adjustment for a wide range of patient characteristics known to be associated with adverse outcomes”. The study author does recognize the limitations of risk adjustment by noting: “while unmeasured confounding almost certainly accounts for at least some of the residual association between discharge status and increased mortality, the persistent increases in mortality after restriction of the cohort and subsequent adjustment for measured covariates raises the possibility that locations after HF hospitalization may play a role in these adverse outcomes.”

Separately, the study published in the American Journal of Medicine provided evidence that the rate at which a hospital discharges heart failure and AMI patients to SNFs cannot be correlated with improved readmission rates. This questions the long-held belief by many case managers that a SNF is the ‘safe option’ for patient discharges.


The Remedy study of the newly developed CARL tool, along with peer-reviewed research, strengthens the case for re-visiting how patients are transitioned from the inpatient setting. There is a growing case for helping patients get home.  

The risk of readmission appears similar, whether patients are discharged to home or to a post acute facility.  The Denver study reports a higher risk of death for patients discharged to SNF, versus patients discharged to their homes. This was a surprising finding and we are trying to better understand all aspects of that research.

When this information is viewed through the lens of Remedy’s CARL software roll out, a new module in our Episode Connect software platform, which was developed to assess patients and their unique situations in order to recommend a site of care following discharge, the implications are significant. Adoption of the CARL tool as part of the patient assessment and discharge process has been shown to reduce post acute spending by over 16%. This reduction in spending appears to be possible without any increase in readmission rates and with no increased risk of death.  In fact, there is some evidence from independent studies that mortality rates actually decline.

If Episode Initiators did nothing else in the Bundled Payment Program but use the CARL software module to guide discharge planning, the data suggests that those programs would immediately improve clinical outcomes while lowering episode spending.