DOI: 10.1097/phm.0000000000002382 ISSN: 1537-7385

Achieving Functional Goals during a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries

Brian Downer, Megan Wickliff, Ioannis Malagaris, Chih-Ying Li, Mi Jung Lee
  • Rehabilitation
  • Physical Therapy, Sports Therapy and Rehabilitation



To describe the frequency that functional goals are documented on the Minimum Data Set (MDS) and identify resident characteristics associated with meeting or exceeding discharge goals.


We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility (SNF) within three days of hospital discharge from 10/01/2018-12/31/2019 (n = 1,228,913). The admission MDS was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance (n = 371,801).


For all self-care items, over 70% of residents had a goal score of 1-6 points documented on the admission MDS. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12-steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals.


Assessing a resident’s functional goals is important to providing patient-centered care. This information may help SNFs determine if a resident has made meaningful functional improvements.

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