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

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.