A study published on March 17, 2025 in JAMA Network Open entitled “Persistence of Delirium in Postacute Care at Skilled Nursing Facilities” stated, in part:
“Annually, more than 2 million Medicare beneficiaries are discharged from acute care hospitals to skilled nursing facilities (SNFs) for postacute care (PAC). Delirium, an acute disorder characterized by fluctuating inattention, confusion, and levels of consciousness, is prevalent among older adults in SNFs and is considered an indicator of quality of care. Research found that 1 in every 4 patients had delirium upon SNF admission. Alarmingly, 64% of these patients exhibited persistent or worsening symptoms a week later, whereas only 14% fully recovered from delirium. Because the persistence of delirium in SNFs is associated with poor outcomes, including hospital readmission, mortality, and long-term institutionalization, identification and management of delirium in this setting hold substantial clinical and policy implications.
The Confusion Assessment Method (CAM), which was introduced to the Minimum Data Set (MDS) in 2012, is measured for every SNF admission. The introduction of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 followed by the 2017 updates to the MDS, which added antipsychotic medication reviews and recommended dose reductions, aimed to improve the quality of PAC. These initiatives, alongside the implementation of the SNF Value-Based Purchasing Program in 2018, which incentivized facilities to reduce hospital readmissions, may have facilitated better recognition and management of delirium in SNFs by standardizing assessment and practices, yet their impact has not been previously examined since.
Thus, we conducted analyses of 2014 and 2019 MDS data to compare rates of persistent delirium, resolved delirium, and mortality during the SNF stay over the 5 years following the implementation of the IMPACT Act. This time frame was selected to provide a sufficient window of opportunity to evaluate the potential outcomes of the policy changes outlined previously. Given that delirium is a common condition with a validated MDS measure, tracking its changes over time presents a unique opportunity to investigate the potential associations of policy interventions with an outcome of substantial clinical relevance.
Of 162 161 beneficiaries admitted to SNFs in 2014, 6933 (4.3%) had delirium at admission. In 2019, 3595 of 144 837 patients (2.5%) had delirium at admission.
This cross-sectional study demonstrates improvements in the resolution of delirium among patients admitted to SNFs between 2014 and 2019, with reductions in both persistent delirium and 30-day mortality. However, the rate of persistent delirium remains concerningly high. Given the negative health consequences of persistent delirium, our findings call for delirium prevention and management strategies in the SNF PAC setting, such as staff training for identifying delirium, the adoption of a systematic delirium prevention and management program such as Hospital Elder Life Program, and multidisciplinary strategies to improve patient care in SNFs.”
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