Action Strategy: High-Risk Readmissions: Skilled Nursing Facility to Home

Readmission after skilled-nursing facility (SNF) discharge following heart failure hospitalization is highest during the first two days home.

Patients discharged with heart failure (HF) from SNF to home face the highest risk of readmissions in the first two days after a SNF discharge.

The study published in the Journal of the American Medical Directors Association reviewed Medicare claims data collected from more than 67,000 beneficiaries. A quarter of heart failure patients discharged from a hospital to a skilled nursing facility then to home are readmitted to a hospital.

The research includes several key data points:

• 24.2% of patients discharged from SNF to home were readmitted to a hospital within 30 days of SNF discharge.
• The risk of readmission was highest in the first two days after SNF discharge.
• Readmission risk declined with longer SNF length of stay.

Patients were followed for 30 days following SNF discharge. The study categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, the study modeled time to a composite outcome of unplanned readmission or death after SNF discharge. The model examined 0-2 days and 3-30 days post-SNF discharge.

“Heart failure patients discharged from hospital to SNF are more medically and functionally complicated than the overall Medicare HF population.”

The authors concluded, “Heart failure patients discharged from hospital to SNF are more medically and functionally complicated than the overall Medicare HF population. Therefore, patients discharged from SNF may benefit from discharge planning because during an SNF stay medications may be started or adjusted, diets may be monitored, and lab tests may be obtained, which may need post-SNF discharge follow-up.”

What Can Be Learned from the Study

1. Interventions to improve post-discharge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.
2. Technology such as front-loading telehealth can monitor patients 24/7 to help prevent readmissions.
3. Home health and at home providers should be part the SNF care transition team to better understand the needs of the patients at home.

Learn more about partnering with skilled nursing facilities.

• Where Do the Highest Risk of Readmissions Come From?