Elsevier

Journal of Cardiac Failure

Volume 22, Issue 12, December 2016, Pages 1004-1014
Journal of Cardiac Failure

Review Article
Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It “Heart Failure Ready?”

https://doi.org/10.1016/j.cardfail.2016.10.009Get rights and content

Abstract

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.

Section snippets

HF Hospital Admissions and Readmissions From SNFs Are Central to Policy Changes

Hospital readmissions have become a widely used metric by which suboptimal care is measured, and, as such, rehospitalization is now a key target of legislative efforts.15, 16 Although causes of readmissions from SNFs are often difficult to deconstruct, HF and/or HF symptoms are frequent triggers.17, 18, 19, 20 In the context of current measured quality metrics, HF is 1 of 13 conditions recognized by The Center for Medicare and Medicaid Services (CMS) as potentially preventable; in other words,

Transitional Care for Patients With HF Admitted to and Discharged From SNFs

Transitions of care (ie, transitional care) occur when patients are transferred between health care settings (ie, from hospital to SNF or from SNF to home) and actions (ie, medical reconciliation, discharge documentation, communication, coordinating patient follow-up, and postdischarge services) are taken to ensure coordination and continuity of care.26 Gaps in transitions contribute to poor outcomes,27, 28 and poor documentation, lack of attention to patient goals and geriatric conditions (eg,

HF Disease Management Approach

Processes to improve assessment and management of patients with HF during their SNF stay are critical determinants of quality and efficacy, but are inherently challenging. An undertrained and unstable SNF workforce, lack of standardized SNF disease management programs (DMP), and limited physician access all contribute to this challenge. Risk prediction tools, monitoring protocols, and DMPs have evolved, but still need to be adapted for SNF patients with HF (Table 1). Designation of disease

Facility Factors

A unique challenge in discharging patients to SNFs is that the facilities themselves lag behind hospitals in experience relevant to achieving quality improvement in HF. Navigating though complexities in care provision within individual facilities can be difficult for providers and families. More than 90% of Medicare beneficiaries live in a county with 3 or more SNFs; fewer than 1% live in a county without one.4 SNF placement is often based on geographic preferences, insurance coverage, or

Future Policy Considerations

Adding regulations on the federal level is a complex challenge; however, we advocate that federal policies are needed to both better assist SNFs in meeting their impending quality mandates, and improve the overall quality of care SNFs provide to the increasing number of patients with HF.

  • 1.

    Classification of SNFs as “HF Ready:” Under newer bundled payment models, hospitals will bear the burden of postacute care costs. Many hospitals currently have broad but weak relationships with postacute care

Conclusions

SNFs are moving to the forefront of care as a key component in the transitional pathway from acute care hospitalization to the community for older patients with HF; however, quality standards to optimize care are still lagging. Better understanding of factors that contribute to optimal care for older patients with HF, who tend to be inherently more complex than younger patients, is an area that requires ongoing investigation and management enhancements. The cardiology community has been

Acknowledgment

Supported by NIH grant R01 HL 113387.

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  • Cited by (0)

    Dr. Forman is supported in part by NIA grants P30 AG024827 and 1R56AG051637-01A1, PCORI grant IH-1304678, and VA Office of Rehabilitation Research and Development grant F0834-R.

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