April 6, 2026
April JAMDA Highlight
By Barbara Resnick, PhD, CRNP
One of our highlighted articles for the current issue of JAMDA is the brief report by Dr. Deardorff and team, Can I Stay, or Must I Go Now? A Cohort Study of Discharge Appeals in a Post-Acute Skilled Nursing Facility.
The focus of this work is on patients who were in skilled nursing facilities for rehabilitation after hospitalization and appealed the discharge plan set by either the skilled nursing facility team or the insurance company covering the rehabilitation. This was a retrospective study and included 453 residents admitted to a single skilled facility for rehabilitation, mostly following orthopedic surgeries such as joint replacements or fractures. Of the 453 residents, 47(10%) filed 58 repeals. Most appeals focused on not feeling ready for discharge, although 15 (32%) had no reason noted in the chart for the appeal. Eight individuals filed multiple appeals.
The residents making these appeals had a mean age of 79 (SD=11) and were split about evenly by gender, with 53% being female and over half being minorities (62%). Twenty residents (43%) were in traditional Medicare, 27 (57%) were in Medicare Advantage plans, and 9 (19%) of the individuals also had Medicaid. Eleven residents (24%) won their appeals, and these individuals had no 30-day rehospitalizations. Two individuals (18%) were discharged on home hospice and died within 30 days.
Conversely, 36 residents (77%) lost their appeals, and 28% of these individuals had a rehospitalization within 30 days, and 0% died within 30 days. There were no differences between the groups with regard to function or functional changes. The length of stay was similar across both groups. Interestingly, a greater percentage of the residents who had Medicare Advantage plans won their appeals (73%) versus those in traditional Medicare (27%).
The findings highlight a few concerns. First, although the number of individuals appealing is not large, it suggests that older individuals, their families, and caregivers may not understand the criteria for subacute rehabilitation or what it takes to be eligible for this level of care. This is reinforced by the fact that the majority of the appeals were not supported. Further, it is a concern that the residents, the family, and the caregivers did not feel ready for discharge. This may be due to the need for services and support beyond the scope of what is provided at a subacute level. For example, they may need help with personal care, home care for such things as wound care or medication management, housekeeping, meal preparation, or grocery shopping.
There were several limitations to this study. First, the study just included one facility, although we all have experienced residents who appeal and can think about how these findings may be relevant. Based on these findings, it may be worth appealing to Medicare Advantage plans rather than traditional Medicare. The residents appealing were not compared to residents who did not appeal.
Future prospective data on this topic would be helpful and could include providers' perspectives on the appeal's appropriateness. Likewise, ongoing education for residents, families, and caregivers is needed to help individuals understand the focus and purpose of subacute care and discuss how to best optimize the discharge to ensure that all care needs are met.
Dr. Resnick is the co-editor-in-chief of JAMDA.