An Updated Mortality and Community Discharge Prognostic Model for Older Adults Admitted to Skilled Nursing Facilities for Post-Acute Care.
W James Deardorff, Siqi Gan, Bocheng Jing and 4 others
PMID 41633538WHAT IT FOUND
Adding skilled nursing facility assessment data to Medicare claims improved prediction of death within six months and return to the community without rehospitalization or death within 30 days.
The model applies to patients still in the facility on day seven.
Key findings
01The final updated MDS model included the MDS-ADL score, cognitive status, oxygen use, urinary incontinence, bowel incontinence, and balance while walking.
02For 6-month mortality, the optimism-corrected c-statistic was 0.747 for the Medicare base model and 0.789 for the updated MDS model.
03For successful community discharge, the optimism-corrected c-statistic was 0.685 for the Medicare base model and 0.730 for the updated MDS model.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
It was developed only from United States Medicare Fee-for-Service beneficiaries, so it may not apply to Medicare Advantage patients or to care systems outside the United States. The study did not test the model in an outside dataset, so its accuracy in other hospitals or facilities is unknown. It only included patients who were still in the skilled nursing facility on day 7 and had a comprehensive assessment, so it does not apply to patients who died, were readmitted, or were discharged before day 7. Successful community discharge depends on things the model does not measure, such as family or caregiver support, neighborhood environment, and attitudes about long-term care. Cognitive status recorded on admission may reflect delirium rather than the patient's usual thinking, and clinicians still need to use their own judgment when interpreting predictions.
Declared interests
The authors declare no conflicts of interest. The supplied metadata indicates NIH and non-U.S. government research support.
The easy way to misread this
Do not use this model as a day-1 tool or as proof that a patient will die or fail to return home. It was developed for patients still in the skilled nursing facility on day 7, and the study did not test whether using it changes patient outcomes.