Positive Beliefs and the Likelihood of Successful Community Discharge From Skilled Nursing Facilities

  • Emily Evans
    Corresponding author Emily Evans, PhD, PT, Department of Health Services, Policy and Practice, Brown University School of Public Health, Box G S121 (6), 121 S. Main Street, Providence, RI 02912.
    Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI
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  • Cyrus M. Kosar
    Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI
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  • Kali S. Thomas
    Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI

    Providence VA Medical Center, Providence, RI
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Published:September 26, 2020DOI:



      To examine the association of patient and direct-care staff beliefs about patients’ capability to increase independence with activities of daily living (ADL) and the probability of successful discharge to the community after a skilled nursing facility (SNF) stay.


      Retrospective cohort study of SNF patients using 100% Medicare inpatient claims and Minimum Data Set resident assessment data. Linear probability models were used to estimate the probability of successful discharge based on patient and staff beliefs about the patient’s ability to improve in function, as well as patient and staff beliefs together. Estimates were adjusted for demographics, health status, functional characteristics, and SNF fixed effects.


      Fee-for-service Medicare beneficiaries (N=526,432) aged 66 years or older who were discharged to an SNF after hospitalization for stroke, hip fracture, or traumatic brain injury.


      Not applicable.

      Main Outcome Measures

      Successful community discharge (discharged alive within 90d of SNF admission and remaining in the community for ≥30d without dying or health care facility readmission).


      Patients with positive beliefs about their capability to increase independence with ADLs had a higher adjusted probability of successful discharge than patients with negative beliefs (positive, 63.8%; negative, 57.8%; difference, 6.0%, 95% confidence interval [CI], 5.4-6.6). This remained true regardless of staff beliefs, but the difference in successful discharge probability between patients with positive and negative beliefs was larger when staff had positive beliefs. Conversely, the association between staff beliefs and successful discharge varied based on patient beliefs. If patients had positive beliefs, the difference in the probability of successful discharge between positive and negative staff beliefs was 2.5% (95% CI, 1.0-4.0). If patients had negative beliefs, the difference between positive and negative staff beliefs was –4.6% (95% CI, –6.0 to –3.2).


      Patients’ beliefs have a significant association with the probability of successful discharge. Understanding patients’ beliefs is critical to appropriate goal-setting, discharge planning, and quality SNF care.


      List of abbreviations:

      ADL (activities of daily living), BMI (body mass index), CI (confidence interval), CMS (Centers for Medicare and Medicaid Services), ICU (intensive care unit), MDS (Minimum Data Set 3.0), SNF (skilled nursing facility), TBI (traumatic brain injury)
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