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BACKGROUND/OBJECTIVES Launched in October 2018, Medicareʼs Skilled Nursing Facility Value‐Based Purchasing (SNF VBP) program mandates financial penalties for SNFs with high 30‐day readmission rates. Our objective was to identify characteristics of SNFs associated with provider performance under the program. DESIGN Retrospective cross‐sectional analysis using Nursing Home Compare data for the 2019 SNF VBP. Facility‐level regressions examined the relationship between structural characteristics (nursing home size, rurality, profit status, hospital affiliation, region, and Star Ratings) and patient characteristics (neighborhood income, race/ethnicity, dual eligibility, disability, and frailty) and facility performance. SETTING US Medicare. PARTICIPANTS A total of 14 558 SNFs. MEASUREMENTS The 2019 SNF VBP performance scores and penalties. RESULTS Nationally, 72% (10 436) of SNFs were penalized; 21% (2996) received the maximum penalty of 1.98%. In multivariate analyses, rural SNFs were less likely to be penalized (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.78‐0.92; P < .001; vs urban), while small SNFs were more likely to be penalized (≤70 beds: OR = 1.28; 95% CI = 1.15‐1.42; P < .001; 71‐120 beds: OR = 1.15; 95% CI = 1.05‐1.26; P = .003; vs >120 beds). SNFs with lower nurse staffing had higher odds of penalties (low: OR = 1.15; 95% CI = 1.03‐1.27; P = .010; vs high); nonprofit and government‐owned SNFs had lower odds of penalties (OR = 0.79; 95% CI = 0.72‐0.87; P < .001; government: OR = 0.72; 95% CI = 0.61‐0.84; P < .001; vs for profit); and SNFs with higher Star Ratings had lower odds of penalties (5 stars: OR = 0.47; 95% CI = 0.40‐0.54; P < .001; vs 1 star). In terms of patient population, SNFs located in low‐income ZIP codes (OR = 1.17; 95% CI = 1.03‐1.34; P = .019) or serving a high proportion of frail patients (OR = 1.39; 95% CI = 1.21‐1.60; P < .001) were more likely to be penalized than other SNFs. SNFs with high proportions of dual, black, Hispanic, or disabled patients did not have higher odds of penalization. CONCLUSION Structural and patient characteristics of SNFs may significantly impact provider performance under the SNF VBP. These findings have implications for policy makers and clinical leaders seeking to improve quality and avoid unintended consequences with VBP in SNFs. J Am Geriatr Soc 68:826–834, 2020

OBJECTIVES We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN Cross‐sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. Setting Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS A total of 5168 residents with a median age of 82 years. MEASUREMENTS Data from 3946 MOQI‐adapted ACTs. RESULTS A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61‐3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38‐3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33‐3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17‐7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9‐25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46‐.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54‐.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68‐.93; P = .003). CONCLUSION Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953–1959, 2019