Readmission Common for HF Patients Discharged to Skilled Nursing Facilities

Marcia Frellick

April 11, 2017

ROCHESTER, MN — Patients hospitalized with a first-time diagnosis of heart failure and discharged to a skilled nursing facility (SNF) were about 50% more likely to be readmitted to the hospital than those who went home from the hospital, in an analysis based on hospital records linked to data from the Centers for Medicare and Medicaid Services (CMS)[1].

The analysis of patients hospitalized from 2001 to 2010, published in the April 2017 issue of Mayo Clinic Proceedings, also identified a cycle of rehospitalization for HF patients discharged from the hospital to an SNF, compared with those discharged to home, that challenges perceptions that SNF care can reduce HF readmissions.

After adjustment for comorbidities, LV ejection fractions, and other features, the patients who were discharged to SNFs showed a hazard ratio (HR) of 1.52 (95% CI 1.31–1.76) for rehospitalization, according to the authors, led by Sheila M Manemann (Mayo Clinic, Rochester, MN).

Of 1498 patients surviving a hospitalization for new heart failure, 605 (40.4%) were discharged to an SNF, which in the current analysis included centers for postacute care as well as long-term-care facilities, or nursing homes, according to the authors. Of those 605 patients, 225 (37%) were admitted to SNFs at least twice.

Although patients are often told their stay will be short, the group found that the average stay in an SNF was 144 days. In addition, the primary reasons HF patients were readmitted to hospitals were not cardiovascular in nature and were potentially modifiable.

According to senior author Dr Veronique Roger (Mayo Clinic), very little had been known about what happens to heart-failure patients after they are discharged to SNFs. To explore the issue, she said, they had to separate out potential influences on a decision to discharge to an SNF instead of home, such as a good support system at home or ability for self-care.

"We've adjusted for a number of factors associated with referral to the nursing facility and still we see a difference in outcomes based on that," she told heartwire from Medscape.

Now, these findings have changed what she tells patients and families as discharge nears. "The average stay is substantially more than what I would have guessed," she said. "That doesn't mean at all that we should cast the blame on skilled nursing facilities. It means we need to address our expectations, as providers and as families."

Also key, Roger said, is letting the patient and families know how important physical activity is once the patient gets to the SNF.

One factor that had a strong correlation to whether a patient was rehospitalized was how well the patients could perform activities of daily living (ADL). The likelihood of hospitalization went up with increased numbers of ADLs with which an HF patient needed assistance.

For example, patients who needed help with five to six ADLs had more than twice the risk of hospitalization compared with those who needed help with no or one ADL (HR 2.12, 95% CI 1.41–3.19), according to the report.

Staffing at SNFs can affect how many times a patient gets to walk per day or practice other ADLs, and that's a problem that's not going away, Roger noted. The analysis, the report says, suggests that SNF staff members may benefit from HF-specific education to improve their confidence in caring for these patients.

Also, she noted, "It's important that the family knows the more they can visit and participate in the care, the better the person is going to be."

Other independent predictors of readmission included chronic kidney disease, arrhythmia, and asthma.

Heart failure affects up to 37% of the nearly 2 million people living in skilled nursing facilities in the US, according to the report.

This study was made possible by grants from the Rochester Epidemiology Project, the National Institute on Aging, and the National Heart, Lung, and Blood Institute. Manemann reports no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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