Heart failure & cardiomyopathies
Skilled Nursing Facility–to–Home Transitions After Heart Failure Hospitalization: A Mixed-Methods Study of Communication, Self-Care, Medication, and Follow-Up
Authors' conclusion
SNF-to-home transitions after HF hospitalization are marked by discordance between patient-reported education and written documentation, as well as inconsistent medication and follow-up coordination. These gaps represent modifiable vulnerabilities during a high-risk recovery period. Standardized HF-focused discharge workflows and strengthened cross-setting communication may improve transitional care, while long-term solutions must address structural and workforce constraints.
Study context
- Population
- Medicare beneficiaries aged ≥65 years discharged from SNF to home following heart failure (HF) hospitalization, with SNF stays ≤60 days
- Participants
- 150 respondents
- Outcome
- Written discharge instructions received (patient-reported)
Methodological details4 nonprofit skilled nursing facilities (SNFs), postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, semi-structured staff interviews
- 4 nonprofit SNFs
- Postdischarge patient and caregiver surveys
- Structured medical record abstraction of discharge instructions
- Semi-structured staff interviews
Main finding
As reported in the abstract
Reported receiving written discharge instructions
59%
Further findings
HF-specific self-care elements documented in instructions
- HF-specific self-care elements (eg, daily weight monitoring, low salt diet) documented
- 15% to 41%
Medication list
- Reported receiving a medication list
- 87%
- Medication list reflected in the discharge instructions
- 53%
- Adherence support addressed
- 24%
Scheduled primary care appointment
- Respondents reporting a scheduled primary care appointment
- 37%
- Documented in discharge instructions
- 13%
Staff interviews
- Nonstandardized discharge workflows, workforce constraints, and reliance on verbal education
Original publication
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