High-Quality Skilled Nursing Facilities Remain Underutilized Among Older US Veterans

Key Takeaways:

• Following hospitalization, most veterans discharged to a skilled nursing facility (SNF) received care at a private facility outside the US Department of Veterans Affairs (VA) rather than a VA nursing home.
• Despite having 4- or 5-star SNFs in their area, 54.9% of veterans attended an SNF with a rating of 4 stars or higher, with only one-third attending the highest-quality SNF available.
• SNF selection and utilization may be impacted by inadequate education and resources as well as restrictive health insurance policies.

For older adults, discharge to high-quality skilled nursing facilities (SNFs) after hospitalization has been associated with better recovery and improved outcomes. However, few studies have assessed SNF utilization, especially among veterans.

Each year, over 175 000 US veterans are discharged from the hospital to SNFs. Veterans have more SNF options available to them as they can select either a VA or non-VA SNF.

Researchers conducted a retrospective descriptive cohort study to analyze access and utilization of high-quality SNFs among veterans. Using a national VA Residential History File (RHF), investigators identified older veterans who were hospitalized and subsequently discharged to SNFs between January 2015 and December 2022.

SNF Utilization Patterns

The study included 662 432 unique veterans with 926 860 hospitalizations followed by SNF admission. Most SNF stays (94.6%) were at private non-VA facilities, and 5.4% of stays were at a VA nursing home.

Only 34.4% of veterans visited the highest-rated SNF within a 16-mile radius while 15.4% attended the lowest-rated SNF. Overall, 54.9% of veterans attended an SNF with a rating of 4 stars or higher.

Nearly two-thirds (64.5%) of veterans had at least 1 higher-rated SNF in their area than the facility they used, and 43.7% had at least 5 higher-quality options available than the SNF used.

Access to High-Quality Care

Most veterans were located within 16 miles of a high-quality SNF; 96.9% had a 4-star SNF, and 88.6% had a 5-star SNF in their area. In general, veterans had approximately 16.4 SNFs of 4 stars or higher in their area.

Veterans who used VA facilities had expanded access, with an average of 18.8 SNFs of 4 stars or higher in their area. However, the proportion of patients who attended the highest-quality VA SNF available was less than those who used the highest-quality non-VA SNF, 31.4% vs 34.6%, respectively.

As age groups increased, utilization of highest-quality SNFs available increased while utilization of the lowest-quality SNF available decreased.

Black veterans were less likely to attend the highest-quality SNF available compared to White veterans, 24.6% vs 35.6%, respectively. In addition, utilization of the highest-quality SNF was lower among veterans with mental health conditions compared to the overall population, 24.9% vs 34.4%, respectively.

Despite having fewer options available, veterans in rural areas were more likely to attend the highest-quality SNF available compared to those in urban areas, 36.1% vs 33.9%, respectively.

Reasons for Suboptimal SNF Utilization

There are 3 requirements to attend an SNF: the veteran must select the specific SNF, the veteran’s payer must approve the SNF, and the SNF must have a bed available and accept the veteran as a patient.

Unfortunately, veterans are not adequately informed or supported when selecting a SNF. Furthermore, certain health plans may limit the number of SNFs available to veterans, and those without coverage might be restricted to VA facilities.

Implications for Veteran Care

Although veterans have expanded access to SNF care, utilization of high-quality facilities remains suboptimal. The authors advise physicians to encourage admission to the highest-quality SNF available to help improve utilization.

According to the authors, “Going forward, improving access to high-quality SNF and improving use of high-quality SNFs are both important and may be relevant quality metrics to track over time."

Reference

Burke RE, Cidav T, Tjader A, et al. Access to and choice of high-quality skilled nursing facility care for veterans after hospitalization: a cohort analysis. J Gen Intern Med. 2026. doi:10.1007/s11606-026-10823-7