Achieving Functional Goals During a Skilled Nursing Facility Stay

Brian Downer, Megan Wickliff, Ioannis Malagaris, Chih Ying Li, Mi Jung Lee

Research output: Contribution to journalArticlepeer-review


Objectives: The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals. Methods: We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 (N = 1,228,913). The admission Minimum Data Set 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). Results: For all self-care items, more than 70% of residents had a goal score of 1–6 points documented on the admission Minimum Data Set. 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. Conclusions: Assessing a resident’s functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.

Original languageEnglish (US)
Pages (from-to)333-339
Number of pages7
JournalAmerican Journal of Physical Medicine and Rehabilitation
Issue number4
StatePublished - Apr 2024


  • Goals
  • Mobility
  • Rehabilitation
  • Self-care
  • Skilled Nursing Facilities

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Rehabilitation


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