Successful Discharge to Community

This indicator measures the percentage of short hospital stays by Medicare nursing home residents (short-stay residents) who successfully return home without needing hospitalization. Nationally, successful discharges occurred for more than half of short-stay Medicare nursing home residents (52 percent). Disparities exist, however, as the rate across each state’s lowest served group by race/ethnicity came in at 44 percent across all states, fewer than half of Black (44 percent) and Hispanic (46 percent) residents had successful discharges. Among the lowest served groups by state, Connecticut, North Carolina, and Wisconsin led the way at close to 52 percent each—at parity with the national rate across all groups.

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†† Due to small sample size of one or more racial/ethnic groups, this indicator could not be calculated.  An imputed value was used for scoring, but is not displayed or ranked.


This is a claims-based outcome measure of the proportion of Medicare beneficiaries, ages 55+, who successfully discharged to the community from a post-acute care (PAC) skilled nursing facility (SNF) and had no subsequent MDS assessment from any facility during the 30 days following discharge to the community.

The denominator for this rate is the Total Admissions, defined as the total number of admissions to the facility for persons 55 and older for individuals with available risk factors within 18 days of the entry date (NOT taken from the discharge assessment), from hospitals, during the year (A1800=03, indicating ‘entered from hospital’) who did not have an MDS assessment from any facility during the previous 100 days (i.e. these were new nursing home admissions and does not include residents hospitalized from a facility). The entry date was determined using 2 variables: A1600 (entry date) and A0310F=01 (indicating ‘entry tracking records’). The numerator is the number of these admissions who were discharged alive to the community (A2100=’01’) from the same facility within 100 days of entry from a hospital and who did not have any subsequent MDS assessment from any facility during the 30 days following discharge to the community.

These data were averaged at the state level following the LTSS State Scorecard approach to measuring equity.

Equity adjustment: Race/ethnicity is indicated in MDS by a 6 category multiple response variable with choices:

  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino
  • Native Hawaiian or Other Pacific Islander
  • White 

Residents were classified by race/ethnicity as follows:

  • Hispanic/Latino: “Hispanic or Latino” is selected
  • All Other Races/Ethnicities: exactly one race/ethnicity is selected (a resident is classified as “Asian” if and only if “Asian” is selected and no other races/ethnicity is selected)
  • Multiracial: “Hispanic or Latino” is not selected and two or more other races/ethnicities are selected

Data are presented for all residents and for each race/ethnicity group for the 10% of facilities nationally and within each state that have the most admissions among each group.

For the equity adjusted metric score, residents are divided into 6 groups: White, American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, and Multiracial.  The lowest performing group is scored and ranked as a performance metric.

Analysis of 2021 MDS 3.0 state-level care data provided by the Changing Long-Term Care in America Project at Brown University in February-April 2023.

Brown University (2023). Changing Long Term Care in America Project at Brown University funded in part by the National Institute on Aging (1P01AG027296). Providence, RI: Brown University School of Public Health, 


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