Skilled Nursing Facility (SNF)

Medicare Part A covers SNF care after a qualifying inpatient hospital stay of at least three consecutive days (some ACOs and waiver programs can waive this). Coverage runs up to 100 days per benefit period: days 1 through 20 are fully covered, and days 21 through 100 carry a daily coinsurance. The patient must need daily skilled nursing or rehabilitation that can only be provided on an inpatient basis. Since October 2019, SNFs are paid under the Patient-Driven Payment Model (PDPM), a case-mix system that, like home health's PDGM, ties payment to patient characteristics rather than therapy volume. SNFs also operate under consolidated billing, and most facilities double as long-term custodial nursing homes paid largely by Medicaid.

Under the Patient-Driven Groupings Model (PDGM), a home health admission within 14 days of discharge from a SNF (or other inpatient facility) is classified as an institutional admission source, which carries higher case-mix weights than community admissions. That makes SNF relationships a direct revenue and acuity signal, not just a referral pipeline. SNF-to-home-health patients arrive with recent therapy records, medication changes, and functional data that should inform the OASIS start of care. Agencies that build structured handoffs with SNF discharge planners, including medication lists, wound records, and therapy progress notes, admit faster and document the institutional stay correctly on the claim.

For many post-surgical and post-acute patients, SNF and home health are substitute settings, and the steering happens at the hospital discharge planning desk. Home health costs Medicare far less per episode than a SNF stay, so hospitals in value-based arrangements, ACOs, and Medicare Advantage plans push hard to send appropriate patients directly home. The "SNF-at-home" movement extends that logic further. For agencies, the pitch to referral sources rests on demonstrated capabilities: front-loaded visits, therapy capacity, timely start of care, and low hospitalization rates. The honest counterpoint: patients without a capable caregiver, with unsafe homes, or needing daily multi-discipline care may genuinely need the SNF first, and pushing them home too early shows up as rehospitalizations.

Practical moves for agency teams:

• Track which SNFs discharge to you, their average lengths of stay, and conversion rates
• Assign liaisons to high-volume facilities and attend discharge planning meetings where permitted
• Stand up a same-day or next-day start of care commitment for SNF discharges
• Capture the institutional admission source with documentation of the SNF discharge date
• Report outcomes back to the SNF, since their referral partners judge them on post-discharge results too