Outreach physiatry clinics in remote Manitoba communities: an economic cost analysis.

BACKGROUND: One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba. METHODS: Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars. RESULTS: Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit. INTERPRETATION: An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

A Nationwide pilot project to develop rehabilitation services for patients with cardiovascular diseases.

OBJECTIVE: To measure progress towards introducing a 3-phase rehabilitation programme, based on the multidisciplinary approach, for patients with cardiovascular diseases. METHODS: Seventeen hospital and outpatient medical centres from 13 regions of the Pilot Project. Baseline questionnaires assessed the involvement of multidisciplinary teams, staffing, and the equipment in healthcare facilities. These questionnaires covered 3 rehabilitation phases: inpatient rehabilitation in the intensive care units and departments of myocardial infarction/cardiac surgery; early in-hospital rehabilitation; and outpatient rehabilitation. RESULTS: The pilot project was initiated in 2013. At the 5-year follow-up, phase I was established across all 17 sites, phase II at 13 sites, and phase III at 9 sites. By 2017, multidisciplinary teams were deployed to manage patients at all sites. Early rehabilitation in regional vascular centres, reduced patients' stay from 13.7 (2.1) days in 2013 to 7.6 (1.1) days in 2017. CONCLUSION: Despite successful implementation of the 3-phase rehabilitation programme based on the multidisciplinary approach, further improvement is required, with the main focus shifted to patients routing between healthcare facilities. Particular attention should be paid to the standards for providing phase III cardiac rehabilitation, in order to ensure continuity of cardiac rehabilitation. The next step should include assessment of the effectiveness of the implemented cardiac rehabilitation programme and its translation to other regions of the country.

A quality indicator set for rehabilitation services for people with rheumatic and musculoskeletal diseases demonstrates adequate responsiveness in a pre-post evaluation.

BACKGROUND: Quality of care is gaining increasing attention in research, clinical practice, and health care planning. Methods for quality assessment and monitoring, such as quality indicators (QIs), are needed to ensure health services in line with norms and recommendations. The aim of this study was to assess the responsiveness of a newly developed QI set for rehabiliation for people with rheumatic and musculoskeletal diseases (RMDs). METHODS: We used two yes/no questionnaires to measure quality from both the provider and patient perspectives, scored in a range of 0-100% (best score, 100%). We collected QI data from a multicenter stepped-wedge cluster-randomized controlled trial (the BRIDGE trial) that compared traditional rehabilitation with a new BRIDGE program designed to improve quality and continuity in rehabilitation. Assessment of the responsiveness was performed as a pre-post evaluation: Providers at rehabilitation centers in Norway completed the center-reported QIs (n = 19 structure indicators) before (T1) and 6-8 weeks after (T2) adding the BRIDGE intervention. The patient-reported QIs comprised 14 process and outcomes indicators, measuring quality in health services from the patient perspective. Pre-intervention patient-reported data were collected from patients participating in the traditional program (T1), and post-intervention data were collected from patients participating in the BRIDGE program (T2). The patient groups were comparable. We used a construct approach, with a priori hypotheses regarding the expected direction and magnitude of PR changes between T1 and T2. For acceptable responsivess, at least 75% of the hypotheses needed to be confirmed. RESULTS: All eight participating centers and 82% of the patients (293/357) completed the QI questionnaires. Responsiveness was acceptable, with 44 of 53 hypotheses (83%) confirmed for single indicators and 3 of 4 hypotheses (75%) confirmed for the sum scores. CONCLUSION: We found this QI set for rehabilitation to be responsive when applied in rehabilitation services for adults with various RMD conditions. We recommend this QI set as a timely method for establishing quality-of-rehabilitation benchmarks, promoting important progress toward high-quality rehabilitation, and tracking trends over time. TRIAL REGISTRATION: The study is part of the larger BRIDGE trial, registered at ClinicalTrials.gov (Identifier: NCT03102814).

Musculoskeletal injury outcomes: 2-year retrospective service evaluation of a UK defence primary care rehabilitation facility (PCRF).

INTRODUCTION: Musculoskeletal injury represents the leading cause of medical discharge from the UK Armed Forces. This study evaluates effectiveness of care provision within a large primary care rehabilitation facility (PCRF) against directed defence best practice guidelines (BPGs) METHODS: All new patient electronic records from January to July 16 were interrogated to identify demographics, causation, injury pathology, timelines and outcomes. RESULTS: 393 eligible records (81.9% male) were identified. 17.6% were officers, 32.8% were seniors and 49.6% were juniors. The average age was 35.1 years (mode 30). The average wait to treatment was 8.3 days with 75.6% key performance indicator compliance. 47.3% were repeat injuries. The average care timeline was 117.1 days with 8.7 average treatment sessions needed. 30 remained under care at 2 years. 17.8% accessed hydrotherapy and 44% underwent exercise remedial instructors care. 14.2% of individuals required concurrent DCMH care (15.9% male and 26.8% female). 28.5% required multidisciplinary injury assessment clinic intervention with 74.1% compliance against BPGs. 2.9% used the Defence Medical Rehabilitation Centre. Common pathologies were low back pain (LBP) (n=67), upper limb (UL) soft tissue (n=40) and knee trauma (n=38). LBP had the highest recurrence rates (71.6%). Anterior knee pain took the longest (173.1 days) but had the best outcome on discharge. Ankles and lower limb muscle injuries had the best outcomes. Patella tendinopathy and knee trauma had the poorest outcome on discharge. LBP and patellar tendinopathy had the lowest fully fit rates at 2 years (56.7% and 53.8%, respectively). At 2 years, 58.2% of individuals achieved full fitness (60.7% men and 46.4% women), rising to 64% and 55%, respectively, when including those retained with limitations. CONCLUSIONS: The PCRF was generally compliant with BPGs, achieving good functional outcomes on discharge. Women were disproportionally represented, had higher concurrent DCMH attendance and poorer overall long-term outcomes. Repeat injury rates were significantly high.

National study for multidisciplinary outpatient oncological rehabilitation: online survey to support revised quality and performance criteria.

PURPOSE: More and more people survive cancer, but the disease and its treatment often lead to impairment. Multidisciplinary ambulatory oncological rehabilitation (OR) programs have thus been developed. SW!SS REHA, the organization of major Swiss rehabilitation clinics, has defined ambulatory OR quality criteria for its members (about 50% of the Swiss rehabilitation capacity). However, SW!SS REHA criteria are not fully implemented and/or interpreted differently by different specialties or in different linguistic regions in Switzerland. The aim of our study was to carry out an online survey of existing outpatient programs to define quality criteria for an ideal OR program in Switzerland. METHODS: A mixed methods approach was used for the survey-qualitative and quantitative. The qualitative part consisted of a guided discussion with OR experts and the quantitative part of an online survey. The quantitative part comprised the development and evaluation of an online questionnaire. It served to record the opinions of OR centers in Switzerland on the desired situation of outpatient rehabilitation. RESULTS: Eighteen OR centers and 71 (49.7% response rate) OR actors participated in the online survey. The survey results indicate that some of the SW!SS REHA quality and performance criteria only partially match with the desired OR criteria for Switzerland. Key disparities occur particularly in the program design and structure and specifically around how many interventions are required to constitute an OR program, the extent of standardization versus individualization of the program, i.e., how many and which modules in a program should be obligatory, and finally the duration and intensity of the program. The online survey did not generate any statistical evidence that OR requirements vary significantly between different linguistic regions and among different specialties. CONCLUSIONS: Cancer patients are heterogeneous with respect to cancer type, prognosis, and disability level, such that a standard program cannot be uniformly applied. Therefore, a flexible program is required with few mandatory modules and additional individual modules to achieve the threshold number of modules that would constitute a multidisciplinary OR program. Intensity and frequency of OR needs to consider the health state of the participants. The results indicate a need to modify some of the existing SW!SS REHA criteria to ensure that more patients can gain access and benefit form evidence-based OR interventions. Furthermore, the survey provides important findings so that the existing OR offer can be improved with the goal that OR centers will be able to be quality certified in the future.

Tolerability and psychological effects of a multimodal day-care rehabilitation program for persons with Huntington's disease.

OBJECTIVE: To determine whether the psychological benefits of intense, inpatient, multimodal rehabilitation for persons with Huntingtons disease (HD), as found in earlier studies, also apply in a shorter, day-care setting. DESIGN: Prospective, non-randomized cohort study. SUBJECTS: Twenty patients attending a group-based 8-week (3 days/week) rehabilitation programme aimed at persons in early stages of HD. METHODS: An explorative cohort study on register data from a specialized rehabilitation centre, includ-ing descriptive data, number of cancellations, a self-reported evaluation, and measures of psychiatric symptoms, health-related quality of life, sense of coherence and physical function at baseline and at the end of rehabilitation. RESULTS: Patients' attendance rate was almost 90%. Patients were satisfied, and displayed significantly reduced anxiety and depression and improved health-related quality of life after rehabilitation. Baseline measures of sense of coherence showed significant negative correlation with the number of cancelled days of rehabilitation. Physical function improved, but did not correlate significantly with psychological outcome measures. CONCLUSION: These results indicate that an 8-week multimodal day-care rehabilitation programme can be tolerable, reduce psychiatric symptoms, and improve health-related quality of life for people with HD. A higher sense of coherence seems to promote attendance rates. Further larger studies, including the impact of cognition and disease progression on the treatment effect, are warranted.

Development of a Multidimensional, Multigroup Measure of Self-Care for Inpatient Rehabilitation.

OBJECTIVE: To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation. DESIGN: Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT). SETTING: Freestanding inpatient rehabilitation hospital in the Midwestern United States. PARTICIPANTS: Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment. RESULTS: CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen dmax-min =1.13; Cohen dlast-first.=0.91) greater than the FIM self-care items (dmax-min.=0.94; dlast-first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM. CONCLUSIONS: This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation.

Functional improvement related to enrolment in a Parkinson's disease rehabilitation program.

BACKGROUND: Parkinson's disease (PD) is a progressive neurodegenerative disorder with manifestations such as tremors, rigidity and bradykinesia. OBJECTIVE: The objective of this study was to evaluate the efficacy of outpatient multidisciplinary rehabilitation. METHODS: 179 patients participated in the six-week program. The following outcomes were measured: Timed Up and Go (TUG), sit to stand five times (STSx5) and in 30 seconds (STS30), six minute walk distance (6MWD) and gait velocity (6MWV), MOCA, bilateral grip strength, 360-degree turn (360 R, 360 L) and bilateral nine hole peg test. Pre- and post- data was analyzed via paired t-tests. Multiple regression was used to determine age- or gender-affected outcomes. RESULTS: Patients showed a statistically significant improvement (p < 0.05) in all outcomes. Mean TUG improved by 1.63 seconds (s), STSx5 by 4.19s, STS30 by 2.37 repetitions, 6MWD by 66.8 metres, 6MWV by 0.15 m/s, MOCA by 1.50 points, 360 R by 1.17s, 360 L by 1.60s, Grip R by 0.78 kg, Grip L by 0.95 kg, 9HP R by 1.71s and 9HP L by 1.58s. Gender had no influence. Age was a statistically significant predictor in STSx5 and 6MW. CONCLUSIONS: An outpatient multidisciplinary program successfully decreased motor impairment and increased overall functional independence in PD.

Possibilities for Quality Assessment of Health Services in Therapeutic Rehabilitation.

The main goal of therapeutic rehabilitation is to provide services that develop, maintain or restore mobility and functionality to the fullest extent possible throughout the patient's life. This process should involve setting real goals both for the person who has mobility and functionality impairment as well as in the records of relevant therapeutic programme objectives. In evaluating this process, quality indicators can be used as 'tools' and they may also be used as parameters for quantitative characterization of healthcare processes and outcomes. The purpose of this paper is to systematise existing knowledge about quality in healthcare in the context of therapeutic rehabilitation, presenting a possible assessment of the level and degree of completion of goals through quality indicators.

Description of health-related rehabilitation service provision and delivery in randomized controlled trials: A topic review.

OBJECTIVE: To determine how health-related rehabilitation services have been described in recently pub-lished randomized clinical trials, using the International Classification System for Service Organization in Health-Related Rehabilitation (ICSO-R 2.0) as a framework. METHODS: Medline was searched for English--language randomized clinical trials (RCTs) published between 1 January 2018 and 31 December 2018. RCTs were eligible if the primary goal was to provide rehabilitation services to targeted patient populations. Two authors independently screened and extracted data, and assessed the methodological quality of eligible trials. Descriptive analysis was used to compare service descriptions between eligible trials and the ICSO-R 2.0 framework (23 categories, 9 categories for provider, 14 categories for delivery). RESULTS: Twenty-nine RCTs, with a wide range of organizational units and target groups, were included. The median number of categories reported in the provider dimension was 4 (range 3-5). The median number of categories reported in the service delivery dimension was 8 (range 6-12). None of the RCTs described all ICSO-R recommended categories. CONCLUSION: Descriptions of service organization in rehabilitation varied widely among recently published randomized clinical trials. Use of the framework for the classification of service organization and standardization of description of services is recommended in future RCTs, to facilitate better comparisons in service research across studies.

Appropriateness of admission to rehabilitation: definition of a set of criteria and rules through the application of the Delphi method.

BACKGROUND: Controlling inappropriateness of care is an essential issue, especially in rehabilitation medicine. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. AIM: The aim was to define clinical admission criteria and rules in rehabilitation medicine. DESIGN: Survey based on the application of the Delphi method on a sample of rehabilitation medicine experts. SETTING: Administration of electronic online questionnaires concerning appropriateness of admission to intensive rehabilitation. POPULATION: Volunteer sample of 53 experts with the following inclusion criteria: being members of the Italian Society of Physical and Rehabilitation Medicine, having practical experience in the research field, agreeing to the confidentiality of the information and being skilled in both rehabilitation and healthcare organization. METHODS: A three-round Delphi survey was conducted according to international guidelines. The two initial rounds consisted of an electronic online questionnaire while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. RESULTS: A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions. The second round was designed according to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, seven criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. CONCLUSIONS: This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. CLINICAL REHABILITATION IMPACT: To increase appropriateness of admission to rehabilitation. Improving appropriateness in healthcare delivery must be a primary goal in order to improve healthcare quality, save money and ensure system sustainability.

Preventing SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments.

SARS-CoV-2 is mainly transmitted by respiratory droplets and contact with contaminated surfaces. It can be retrieved in faeces but there is no evidence of faecal-oral transmission, which is the main route of contamination in recreational waters. Standard cleaning and disinfecting procedures, microbiological control and health rules aim to prevent infectious risk regardless of the micro-organisms. In the context of progressive lockdown exit and hospital activities recovery, we assessed the risk of SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments in order to provide specific recommendations to control the spread of SARS-CoV-2 while ensuring essential rehabilitation care for patients.

Implementing Patient-Reported Outcome Measures in Outpatient Rehabilitation Settings: A Systematic Review of Facilitators and Barriers Using the Consolidated Framework for Implementation Research.

OBJECTIVE: This systematic review examines the facilitators and barriers to the use of patient-reported outcome measures (PROMs) in outpatient rehabilitation settings and provides strategies to improve care to maximize patient outcomes. DATA SOURCES: Eleven databases were systematically searched from November 2018 to May 2019. STUDY SELECTION: Two reviewers independently assessed articles based on the following inclusion criteria: English text, evaluate barriers and facilitators, include PROMs, and occur in an outpatient rehabilitation setting (physical therapy, occupational therapy, speech language pathology, or athletic training). Of the 10,164 articles initially screened, 15 articles were included in this study. DATA EXTRACTION: Data were extracted from the selected articles by 2 independent reviewers and put into an extraction template and into the Consolidated Framework for Implementation Research (CFIR) model. The Appraisal Tool for Cross-Sectional Studies (AXIS) was conducted on each study to assess study design, risk of bias, and reporting quality of the eligible studies. DATA SYNTHESIS: Ten studies were identified as high quality, according to the AXIS. Based on the CFIR model, the top barriers identified focused on clinician training and time in the implementation process, lack of recognized value and knowledge at the individual level, lack of access and support in the inner setting, and inability of patients to complete PROMs in the intervention process. Facilitators were identified as education in the implementation process, support and availability of PROMs in the inner setting, and recognized value at the individual level. CONCLUSIONS: More barriers than facilitators have been identified, which is consistent with PROM underuse. Clinicians and administrators should find opportunities to overcome the barriers identified and leverage the facilitators to improve routine PROM use and maximize patient outcomes.

Safe and Supportive Neurorehabilitation Environments: Results of a Structured Observation of Physical Features Across Two Rehabilitation Facilities.

OBJECTIVE: This research aimed to identify the extent to which physical features of two neurorehabilitation units appeared to support positive patient experience and recovery. BACKGROUND: Neurorehabilitation inpatient facilities must be focused on safety management and efficiency of care, as well as being supportive of the patient experience. While occupational safety and risk management is paramount, the supportive nature of the physical setting for inpatient neurorehabilitation following spinal cord injury or acquired brain injury is unclear. METHOD: Structured observation of two physical environments using an adapted observational tool comprising 237 items across 8 area zones, and 3 major categories (patient safety, worker safety and efficiency, and holistic patient experience). RESULTS: Results indicated that across both neurorehabilitation settings, the built environment attended well to occupational safety, risk reduction, harm prevention and internal security (up to 87% in spinal injury unit [SIU] and 95% in brain injury unit [BIU] patient rooms), but with limited evidence of physical features to support psychosocial needs or promote positive user experiences (up to 30% in SIU and 45% in BIU patient rooms). CONCLUSION: The built environments observed appeared to be an underutilized resource for supporting positive psychosocial neurorehabilitation experiences (including complex behavior support) beyond hazard management.

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems.

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Implementation of an Evidence-Based, Nurse-Driven Sepsis Protocol to Reduce Acute Care Transfer Readmissions in the Inpatient Rehabilitation Facility Setting.

PURPOSE: The aim of this study was to determine if implementing an evidence-based, nurse-driven sepsis protocol would reduce acute care transfer (ACT) readmissions from an inpatient rehabilitation facility compared to nonprotocolized or usual standard of care for adult sepsis patients undergoing physical rehabilitation. DESIGN: This study used a preintervention and postintervention model for quality improvement, which involved comparing the nonprotocolized care of adult sepsis patients in the inpatient rehabilitation population to the application of an evidence-based, nurse-driven sepsis protocol to determine its effect on reducing ACT readmissions. METHODS: Patients who screened positive for suspected sepsis and received protocolized interventions were analyzed to determine the occurrence of ACT readmission. Compliance with protocol elements was also evaluated. FINDINGS: The sepsis-related ACT readmission rate decreased from 36.28% to 25% in 8 weeks, and compliance with protocolized sepsis interventions increased. CONCLUSIONS: Nurse-driven, protocolized assessment and treatment can improve the management and care of sepsis patients undergoing physical rehabilitation and can reduce ACT readmissions. CLINICAL RELEVANCE: This review provides rehabilitation nurses an evidence-based, nurse-driven approach to the clinical management of sepsis patients in the inpatient rehabilitation setting and discusses how this approach can reduce ACT readmissions and improve clinical outcomes.

What Characteristics Influence Whether Rural Beneficiaries Receiving Care From Urban Hospitals Return Home for Skilled Nursing Care?

PURPOSE: Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home. METHODS: The population includes Medicare beneficiaries who live in a rural area and received acute care from an urban facility in 2013. "Near home" was defined 3 different ways based on distances from the beneficiary's home to the nearest source of SNC. Results include unadjusted means and odds ratios from logistic regression. FINDINGS: About 69% of rural beneficiaries receiving acute care in an urban location returned near home for SNC. Beneficiaries returning home were white (odds ratio [OR] black: 0.69; other race: 0.79); male (OR: 1.07); older (OR age 85+ [vs 65-69]: 1.14); farther from SNC (OR: 1.01 per mile); closer to acute care (OR: 0.28, logged miles); and received acute care from hospitals that did not own a skilled nursing facility (owned OR: 0.77) and hospitals with: no swing bed (swing bed OR: 0.47), high case mix (OR: 3.04), and nonprofit status (for-profit OR: 0.85). Results varied somewhat across definitions of "near home." CONCLUSIONS: Rural Medicare beneficiaries who received acute care far from home were more likely to receive SNC far from home. Because Medicare beneficiaries have the choice of where to receive SNC, policy makers may consider ensuring that new payment models do not incentivize provision of SNC away from home.