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URSA-PHF-053: SNF 30-Day Readmit to Hospital Inpatient

  • Published on Aug 19, 2026
  • 4 minute(s) read
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Measure Description

Among SNF discharges to the community (e.g., excludes deaths, transfers, etc.), the percentage with at least one instance of an acute hospital inpatient admission within 30 days following discharge from the SNF.

Metadata

  • Measure Identifier: URSA-PHF-053
  • Measure Type: Rate Measure
  • Temporal Structure: Event
  • Component Class: Normal-Form
  • Case Field: SNF Encounter ID
  • Observation Field: SNF Encounter ID
  • Target Direction: Down

Denominator Description

One per qualifying SNF discharge, excludes discharges with a CMS patient status code indicating the patient did not go home (e.g., death, transfer, left AMA).

Numerator Description

One per hospital inpatient admission

Published Fields

  • Data Model Keys

    • SNF Encounter ID
    • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
    • SNF Facility Provider ID

  • Date Fields

    • SNF Encounter Start Date
    • SNF Encounter End Date
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

  • Encounter Fields

    • Is SNF Swing-Bed SNF Encounter
    • SNF Encounter LOS in Elapsed Midnights
    • SNF Encounter LOS in Distinct Calendar Days
    • SNF Encounter Calendar Days LOS Category Tier 1
    • Is SNF LOS in Days > 100
    • Is SNF Discharge Status Home or Home with Home Health

  • Provider Fields

    • SNF Facility Provider Description
    • SNF Facility Provider Primary NUCC Provider Taxonomy Description

  • Location Fields

    • SNF Facility Provider Practice Address ZIP Code 5-Digit
    • Patient State Abbreviation
    • Patient ZIP Code 5-Digit
    • UW HIP Area Deprivation Index National Percentile -- A value between 1 and 100 representing the composite measure of socioeconomic deprivation from University of Wisconsin’s School of Medicine and Public Health. Scores are for Census Block Group geographic level, which generally contains between 600 and 3,000 people. Higher scores indicate more deprivation, so a score of 1 indicates the least deprivation while a score of 100 indicates the most deprivation. Percentiles are constructed by ranking the ADI from low to high for the nation and grouping the block groups into bins corresponding to each 1% range of the ADI. The 2019 ADI was constructed using the 2015-2019 5-year estimates from the US Census' American Community Survey and includes 17 component measures that span the domains of income, education, employment, and housing quality. It may be linked with the 9-digit ZIP code crosswalk, which was built to correspond directly to Census block groups. The 2019 ADI was released on 07/14/2021 and is the most recent version as of 02/02/22.
    • UW HIP ADI Quintile Category -- The UW HIP Area Deprivation Index National Percentile grouped into 5 levels, each spanning 20 percentile points (ADI 1 is percentile scores from 1 to 20 while ADI 5 is scores from 81 to 100). Higher scores indicate more deprivation, so ADI 1 is the least deprived while ADI 5 is the most deprived. Quintiles are frequently used in health research. They give larger sample sizes per group and are easier to plot and interpret. Quintiles also carry less information and group more dissimilar patients. Quintiles are good for descriptive analyses while the original percentile measure is preferable for predictive modeling. (See also [URSA-CORE] UW HIP Area Deprivation Index National Percentile)
    • UW HIP ADI Decile Category

  • Diagnosis Fields

    • SNF Principal Discharge Diagnosis ICD-10-CM Code
    • SNF Principal Discharge Diagnosis ICD-10-CM Description
    • SNF Principal Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Code
    • SNF Principal Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Description
    • CCW Count Category
    • Count CCW Conditions -- The total of both Chronic Conditions and Potentially Disabling Events included in the CMS Chronic Condition Warehouse (CCW) library. (See also [URSA-CORE] CCW Comorbidity Category, [URSA-CORE] Count Potentially Disabling Events, [URSA-CORE] CMS Chronic Condition Warehouse (CCW), [URSA-CORE] Count Chronic Conditions)

  • Billing and Claims Fields

    • SNF CMS Patient Discharge Status Code
    • SNF CMS Patient Discharge Status Description

  • Financial Fields

    • SNF Total Plan Paid Amount from All Plans
    • SNF Encounter Total Plan Paid Amount Category

  • Numerator Fields

    • Numerator Encounter ID
    • Numerator Facility Provider ID
    • Numerator Encounter Start Date
    • Numerator Encounter End Date
    • Numerator Ursa Hospital Admission Condition-Treatment Type Tier 1 Category
    • Numerator Inpatient LOS Category Tier 1
    • Is Numerator Inpatient LOS < 2 Midnights
    • Numerator Inpatient LOS in Elapsed Midnights
    • Numerator Inpatient LOS in Distinct Calendar Days
    • Is Numerator Emergency Department Visit Parent Encounter
    • Is Numerator Observation Stay Parent Encounter
    • Is Numerator IRF Parent Encounter
    • Is Numerator LTCH Parent Encounter
    • Is Numerator IPF Parent Encounter
    • Is Numerator Discharge Status Home or Home with Home Health
    • Numerator Primary HCPCS Procedure HCPCS Code
    • Numerator Primary HCPCS Short Description
    • Numerator Principal ICD Procedure ICD-10-PCS Code
    • Numerator Principal ICD Procedure ICD-10-PCS Description
    • Numerator Principal Discharge Diagnosis ICD-10-CM Code
    • Numerator Principal Discharge Diagnosis ICD-10-CM Description
    • Numerator Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Code
    • Numerator Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Description
    • Numerator Facility Provider Description
    • Numerator Facility Provider ZIP Code 5-Digit
    • Numerator MS-DRG Code
    • Numerator MS-DRG Description
    • Numerator MS-DRG MDC Code
    • Numerator MS-DRG MDC Description
    • Numerator CMS Admit Type Description
    • Numerator CMS Admit Source Description
    • Numerator CMS Patient Discharge Status Description
    • Numerator Total Plan Paid Amount from All Plans

  • Measure Fields

    • Denominator