The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations

Objectives: To examine characteristics and locations of high- and low-quality skilled nursing facilities (SNFs) and whether certain vulnerable individuals were differentially discharged to facilities with lower quality ratings.

Design: Retrospective observational study.

Setting: Medicare-certified SNFs providing postacute care.

Participants: SNF stays (N=1,195,166) of Medicare beneficiaries aged 65 and older admitted to 14,033 SNFs within 2 days of hospital discharge.

Measurements: We used Medicare claims from October 2013 to September 2014 and SNF 5-star ratings published on Nursing Home Compare. We describe the characteristics and populations of facilities according to quality, and the location of low (1 star) and high (5 stars) quality facilities. We used logistic regression models to estimate odds of admission to a low-quality facility after hospital discharge according to race, ethnicity, dual Medicare-Medicaid enrollment, functional status, discharge from a safety-net or low-quality hospital, and residence in a county with more low-quality SNFs.

Results: More than one-fifth (22.2%) of the facilities had a 5-star (high quality) rating, and 15.9% had a one-star (low quality) rating. Low-quality facilities were more likely to be in the south (44%), for profit (85%), and larger (>70 beds (86%)). Dual enrollment was the strongest predictor of admission to a 1-star facility (odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.51-1.55), although racial or ethnic minority status (black: OR = 1.25, 95% CI = 1.22-1.28; Hispanic: OR = 1.10, 95% CI = 1.06-1.14) and geographic prevalence of facilities (for a 10% increase in 1-star beds located in the county of individual's residence: OR = 1.27, 95% CI = 1.26-1.27) were also significant predictors.

Conclusion: Vulnerable groups are more likely to be discharged to lower-quality facilities for postacute care. Policy-makers should monitor disparities in SNF quality. J Am Geriatr Soc 67:108-114, 2019.