Faith Affiliation and Nursing Home Hospitalization Performance: Evidence from a National Stratified Sample

Background and ObjectivesSkilled nursing facility (SNF) hospitalization rates vary substantially across facilities serving comparable patient populations, yet the organizational factors underlying high performance remain poorly characterized. This study examines whether faith or mission-driven organizational identity is associated with lower-than-expected hospitalization rates in a national sample of Medicare-certified SNFs. DesignCross-sectional analysis of a stratified random sample of 618 Medicare-certified SNFs, drawn from a national cohort of 13,419 facilities with claims-based quality data. Facilities were classified by organizational identity (faith-affiliated, purpose-driven, or secular) using publicly available records. Performance was measured using CMS claims-based hospitalization and emergency department transfer rates adjusted for expected rates given patient case mix. Setting and ParticipantsMedicare-certified skilled nursing facilities in the United States, February 2026 CMS release. MethodsWe computed a composite performance gap as the mean of four z-scored observed-minus-expected measures (short-stay and long-stay hospitalization and ED transfer rates). We tested the association between faith affiliation and performance using Fishers exact test, logistic regression, OLS regression, propensity score matching, and causal mediation analysis. ResultsFaith-affiliated or purpose-driven facilities constituted 14.7% of significant overperformers (95% CI: 7.0-23.5%) and 0% of significant underperformers (95% CI: 0.0-4.4%), a monotonic gradient confirmed across all five performance zones. After propensity score matching on facility size, ownership type, and urbanicity (n=49 matched pairs), faith-affiliated facilities achieved 18.2% short-stay rehospitalization compared to 21.7% for matched secular facilities (3.5 percentage points fewer, p=0.019), and 1.30 long-stay hospitalizations per 1,000 resident-days compared to 1.71 (0.41 fewer per 1,000 days, p=0.019). Faith affiliation was associated with 61% more RN staffing hours per resident per day (0.96 vs. 0.60 hours, p<0.001), and formal mediation analysis confirmed that RN staffing hours substantially mediated the relationship between faith affiliation and hospitalization performance. Conclusions and ImplicationsFaith and mission-driven organizational identity is associated with superior hospitalization performance in a national SNF sample, mediated by elevated RN staffing intensity. These findings suggest that organizational culture and values are modifiable upstream determinants of nursing home quality, with implications for quality improvement, workforce policy, and value-based payment design.