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Medical care in skilled nursing facilities (SNFs) in the United States

Mark Yurkofsky, MD
Joseph G Ouslander, MD
Section Editor
Kenneth E Schmader, MD
Deputy Editor
Daniel J Sullivan, MD, MPH


Skilled nursing facility (SNF) care in the United States includes both long-term residential care and short-term post-acute or rehabilitative care. While the number of Americans living in SNFs for extended periods has fallen steadily over the past decade as an increasing proportion of older individuals remain in their homes or in assisted living facilities, the number receiving short-term nursing care has risen dramatically. In 2014, 1.7 million fee-for-service (FFS) Medicare beneficiaries were cared for in 15,000 SNFs, costing Medicare USD $28.6 billion. This represents 2.4 million SNF stays: 20 percent of all hospitalized FFS Medicare beneficiaries are discharged to a SNF. The majority of these facilities are the same institutions as those providing residential long-term care: 95 percent of SNFs provide both kinds of care [1].

SNF residents, whether short- or long-term, tend to be old, female, and have multiple impairments in their activities of daily living (ADLs). Of those in SNFs in 2014, 16.6 percent were between the ages of 65 and 74, 26.6 percent were between 75 and 84, 33.7 percent were between 85 and 94, and 7.8 percent were 95 years of age or older [2]. In the same population, 6.1 percent had impairments in three ADLs, 41.2 percent had impairments in four ADLs, and 22.4 percent had impairments in five ADLs. Cognitive impairment is also widespread in this population, with 36.9 percent exhibiting severe impairment, 24.9 percent having moderate impairment, and 38.2 percent with mild or no impairment [2].

SNF care represents a substantial segment of health care costs for older individuals: in the United States in 2010, $143 billion was spent on SNF care, of which 14 percent was paid by Medicare, 63 percent by Medicaid, and 22 percent privately [3]. The costs of care are covered differently, depending on whether the patient is receiving long- or short-term care:

Long-term residents live at the facility and are often described as receiving “custodial care.” Room and board costs for this group are generally paid for by Medicaid, long-term care insurance, or out-of-pocket by residents or their families.

For most short-term patients discharged from a hospital setting, the goal is to return to the community. A subset of these patients may be at the SNF for short-term end-of-life care and some will require long-term care. Room and board costs are generally paid by their SNF benefit, which, in the case of Medicare, covers up to 100 days per benefit period if care needs meet specific clinical criteria. Clinical criteria include the need for rehabilitation to regain function due to deconditioning, and/or medical instability requiring frequent nursing and/or medical intervention. In the Medicare FFS system, a patient must be in an acute hospital as an inpatient for 72 hours (three midnights) to qualify for the SNF benefit. Although the benefit can last for 100 days, a substantial copay is required after day 21. The average length of stay in a Medicare-covered SNF post-acute episode is about 25 days and is declining. Some Medicare-managed care and bundled payment programs can obtain a waiver of the 72-hour rule and directly admit patients to the SNF. The length of stay for these patients is generally shorter because of the financial incentives for care at the lowest level that is safe and feasible.

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Literature review current through: Sep 2017. | This topic last updated: Oct 18, 2017.
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