Kwadwo Kyei Boahene
Despite more than a decade of value-based reimbursement under the Hospital Readmissions Reduction Program and the Skilled Nursing Facility Value-Based Purchasing program, 30-day readmission rates from US post-acute care (PAC) settings remain at 20% to 25% among skilled nursing facility residents and contribute more than $15 billion annually to Medicare expenditure. Elevated rates have persisted despite sustained policy attention. This suggests that the dominant clinical quality frame captures only part of the problem. The operational substrate of PAC transitions, therefore, warrants systematic examination. The objective is to synthesize peer-reviewed and gray literature published between 2021 and January 2026 on the operational determinants of preventable readmissions from US PAC settings and to map evidence-based interventions to each determinant domain. A structured narrative review was conducted following the Scale for the Assessment of Narrative Review Articles guidance. PubMed, CINAHL, and Google Scholar were searched alongside targeted gray literature retrieval from the Centers for Medicare & Medicaid Services, Medicare Payment Advisory Commission, Agency for Healthcare Research and Quality, Office of the National Coordinator for Health Information Technology, American Heart Association, and the Leonard Davis Institute. Of 312 records identified, 41 were retained after screening for US PAC relevance, operational focus, and currency. This review pursues a single aim: to identify these operational determinants and organize them within a 6-domain framework, pairing each determinant with the interventions that target it. The literature converges on 6 operational determinants: discharge protocol heterogeneity and role ambiguity, referral to capacity mismatch, gaps in bidirectional information exchange (only about 1 in 6 hospitals routinely transmits structured summary of care records to PAC providers), workforce attrition, role conflation, and limited operational authority, inconsistent screening and integration of social determinants of health, and asymmetric financial incentives. Targeted operational interventions across all 6 domains have demonstrated meaningful effects in controlled and single-site evaluations, though scalability evidence is uneven. Many preventable readmissions from PAC follow from how care is organized across hospitals, post-acute providers, payers, and community services, rather than from isolated clinical failures. Practical reduction requires coordinated intervention across all 6 determinants; single-domain interventions consistently underperform when deployed in isolation.