Factors associated with discharge to skilled nursing despite a clinical recommendation for inpatient rehabilitation

BACKGROUND AND PURPOSE: Two-thirds of adults with stroke receive post-acute rehabilitation to enhance recovery. For many, higher-intensity, but more costly, rehabilitation at an inpatient rehabilitation facility (IRF) is associated with improved outcomes compared to a skilled nursing facility (SNF). Little is known on how often patients recommended for IRF discharge actually discharge to SNF. Ensuring patients receive post-acute care that aligns with clinical need is crucial for long-term outcomes. This study examined how often patients recommended for an IRF discharge after stroke hospitalization discharge to a SNF, and examined the factors associated with this discrepant discharge. METHODS: Retrospective cohort study of adults hospitalized for stroke in a multi-hospital health system between January 1, 2018 - December 31, 2024. Electronic health record data identified physical and occupational therapy recommendations for an IRF discharge and the post-discharge location (IRF or SNF). A generalized logistic regression examined factors associated with SNF discharge. RESULTS: Among 3388 stroke hospitalizations which recommended IRF, 3092 (91%) discharged to IRF and 296 (9%) discharged to SNF. Enrollment in Medicare Advantage (OR=2.80, 95%CI [1.68, 4.68]), traditional Medicare (OR=2.05, 95%CI [1.22, 3.43]), age ≥ 85 years (OR=1.98, 95%CI [1.17, 3.37]), dependent pre-admission mobility (OR=1.81, 95%CI [1.21, 2.70]), and acute hospital length of stay (OR=1.03, 95%CI=[1.02, 1.04] were most strongly associated with a discrepant discharge. CONCLUSIONS: Among those recommended for IRF discharge, a SNF discharge was driven by a combination of both clinical and non-clinical factors. These results underscore the need to consider how both clinical and non-clinical factors influence this process and may impact long-term outcomes.