Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure.

SNFs are often used as a transition from hospital to home to regain strength, function, and independence, particularly for medically complex patients. Discharge home from SNF is often the ultimate goal, as the vast majority of these patients were residing at home prior to hospitalization. However, these are vulnerable patients, and SNF stays add another layer of complexity to the final transition back to the community. Although the level of care at an SNF is less intense than in an inpatient facility, they are still medical settings with daily nursing care and physician oversight. During this SNF stay, new medications may be started, medication adjustments may occur, and lab tests may be obtained, which may be still pending at the time of SNF discharge.

Understanding the risk trajectories associated with the transition from SNF to home is important on multiple fronts Share on X

Although several studies have examined the transition from hospital to home among patients with heart failure, much less is known about transitions from SNF to home, including associated risks of readmission and mortality. As Medicare pays for SNF at full cost only for the first 20 days after hospital discharge, many patients may be discharged on day 21, a time period within the 30-day readmission window of interest to health care systems trying to avoid readmission penalties. Furthermore, in October 2018, the Centers for Medicare and Medicaid (CMS) implemented the Skilled Nursing Facility Value-Based Purchasing Program, which offers Medicare incentive payments to SNFs paid under the SNF Prospective Payment System related to performance on specified measures of readmissions. Thus, understanding the risk trajectories associated with the transition from SNF to home is important on multiple fronts.

A study published by JAMDA found that the rate of hospital readmissions was almost a quarter of all patients after transitions from SNF to home; however, the rate of hospital readmission decreased as the length of stay in SNF increased.

To read the full study, please click HERE.