A measurement of resident preparedness for leaving a skilled nursing facility accurately predicted that more than half of study participants did not need acute care within 30 days of going home, according to a study. However, men and white patients who did have to go back to the hospital or emergency room from the nursing home had longer acute care compared to women and people from other backgrounds. The [study](https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-025-05803-1) was published Tuesday in _BMC Geriatrics_.
Researchers measured preparedness in 30 days after discharge from a SNF. They also gauged how patient and social determinants affected preparedness. Understanding this is key because, despite [discharge planning](https://www.mcknights.com/news/advocate-collaborate-for-successful-snf-discharges-expert/) from SNFs to home, about 22% of older adults are readmitted to the hospital within 30 days of getting home.
Researchers wanted to evaluate the Care Transitions Measure-15 (CTM-15) to see if it was a good predictor of outcomes. The CTM-15 is a 15-item scale e with scores that range from 0 to 100. The higher the score, the better a person was prepared to leave the facility. The team also looked at the Charlson Co-morbidity Index score to measure health.
Data was derived from 249 patient and caregiver groups at six skilled nursing facilities located in North Carolina. The time span studied included 30 days after people were transferred from an SNF to their home. Patients were 76.4 years old on average, and 63.8% were women.
The average CTM-15 score was 72.9, and the average days of acute care use within 30 days of SNF discharge was 0.62. The average number of acute care days went down 33% among males, while white people had a 25% reduction in acute care days. People with a low area deprivation score had a 31% reduction in acute care use, while patients with a high Charlson total score had a 22% reduction in acute care use.
During the 30-day follow-up after discharge,14% of residents had to seek acute care. Some 21 older adults were readmitted to the hospital and 14 older adults had to go to the emergency department. Overall, just three patients needed more than seven days of acute care.