Successful return to home and community from a SNF

This measure asks whether residents who finished a SNF stay went home and stayed there: discharged to the community, alive, and out of the hospital for the next 31 days. It comes from claims, covers two years, and is one of the two Five-Star short-stay measures where a higher rate is better.

What it measures

Five-Star calls it the rate of successful return to home and community from a SNF. Its definition matches the SNF Quality Reporting Program measure Discharge to Community—Post Acute Care, CMS ID S005.02, which CMS describes as a risk-standardized rate of Original Medicare residents discharged to the community who don’t have an unplanned readmission to an acute care hospital or long-term care hospital and stay alive for 31 days. “Community” means home or self-care, with or without home health services.

It is worth up to 150 points in Five-Star’s short-stay rating. Unlike the other short-stay measures, it uses two years of data, and it needs at least 25 stays to be publicly reported.

What counts as a successful return

Where the resident went is read from the SNF’s claim, not the MDS.

A discharge on one of those codes is then taken back out of the numerator if the resident died during the stay or within 31 days after it, or had an unplanned readmission to an acute hospital or long-term care hospital within 31 days, counting the day of discharge. CMS uses its Planned Readmission Algorithm to decide what was planned, and treats every inpatient psychiatric stay as planned.

Which stays are left out

A SNF stay is excluded if the resident:

• Was under 18.
• Wasn’t discharged from an acute care or inpatient psychiatric hospital in the 30 days before the SNF admission, or that hospital stay was for non-surgical cancer treatment.
• Left against medical advice.
• Was discharged to an inpatient psychiatric hospital, to another SNF, to a federal hospital or disaster site, or to court or law enforcement.
• Was discharged to hospice, or had a hospice benefit period within 31 days of discharge.
• Wasn’t continuously enrolled in Medicare for 90 days before admission and 31 days after discharge.
• Exhausted their Medicare benefits during the stay, or has records CMS can’t reconcile.
• Was a long-term nursing home resident in the 180 days before the hospital stay (found from OBRA assessments) and hadn’t been discharged to the community from that stay.
• Had a planned discharge to an acute hospital, psychiatric hospital or long-term care hospital.

Stays in a critical access hospital swing bed and stays outside the U.S. states and territories are also left out. The long-term resident exclusion is one place the MDS matters, since CMS finds those residents from their OBRA assessments. A resident who lived in a nursing home before the hospital stay isn’t expected to go “home” to the community.

Risk adjustment

CMS adjusts for the resident’s age and sex, how they became entitled to Medicare (end-stage renal disease or disability), the principal diagnosis and any surgery in the hospital stay before admission, comorbidities, dialysis, the length of that hospital stay and any intensive care days, ventilator use during the SNF stay, and other hospital stays in the prior 90 days.

The model is hierarchical: it estimates each building’s own effect, but pulls it toward the national average when the building has few stays. The final rate is the building’s predicted number of successful returns divided by the number expected for the same residents at an average SNF, times the national rate.

CMS’s September 2026 technical report describes an updated version that adds Medicare Advantage encounter records alongside Original Medicare claims, with Medicare Advantage coverage as a new risk factor. The Five-Star Technical Users’ Guide (September 2026) still describes the measure’s risk adjustment as using Medicare enrollment data and Part A claims, so check which version a given Care Compare refresh uses.

Common mistakes

• A claim whose discharge status code doesn’t match where the resident went. The measure believes the claim.
• Treating the discharge date as the end of the building’s responsibility. The 31 days after it count.
• Expecting it to move fast. With two years of stays in it, one quarter’s work moves it slowly.

How Five-Star scores it

Buildings are ranked by decile, 15 to 150 points, against cut points set from 2016Q4 to 2017Q3 data. Higher is better.

SuperQM shows this measure beside the short-stay measures your MDS drives, so the whole short-stay rating is in one place.