Bridging the Gap: Improving Skilled Nursing Facility-to-Home Transitions for Heart Failure Patients

Highlight

1. Significant discrepancies exist between patient-reported discharge education and the documentation in skilled nursing facility (SNF) discharge instructions after heart failure (HF) hospitalization.
2. Heart failure-specific self-care instructions, such as daily weight monitoring and low-salt diets, are inconsistently included in discharge documents.
3. Medication lists are frequently provided to patients but are not consistently reflected in written discharge instructions, with limited adherence support.
4. Follow-up care coordination is suboptimal, with a low proportion of documented and scheduled primary care or specialist appointments post-discharge.
5. System-level challenges including nonstandardized workflows, workforce constraints, and reliance on verbal education contribute to variability in transitional care quality.

Study Background

Heart failure (HF) is a leading cause of hospitalization among older adults and is associated with high rates of readmission and mortality. Skilled nursing facilities (SNFs) serve as a critical bridge in postacute recovery, particularly for older Medicare beneficiaries following HF hospitalization. Transitions from SNFs to home represent vulnerable periods marked by risks for adverse events, including medication errors, inadequate self-care, and poor follow-up, all of which can precipitate rehospitalization. Despite clinical guidelines emphasizing comprehensive discharge planning, including clear communication, HF-specific self-care education, medication reconciliation, and follow-up coordination, the implementation of these guidelines during SNF-to-home transitions remains understudied. Addressing these gaps could lead to improved outcomes and reduced healthcare utilization during this high-risk phase.

Study Design

This convergent mixed-methods study was conducted across four nonprofit SNFs. The participant cohort comprised Medicare beneficiaries aged 65 years or older who had been hospitalized for HF and subsequently discharged from SNFs to home within 60 days. The study integrated multiple data sources: patient and caregiver postdischarge surveys capturing perceived discharge education and follow-up, structured abstraction of medical records focusing on discharge instructions, and semi-structured interviews with SNF clinical staff to explore barriers and facilitators to optimal discharge processes. Quantitative data were analyzed descriptively, while qualitative data underwent thematic and directed content analysis. Triangulation of findings enhanced the validity of identified challenges and potential strategies for improving SNF-to-home transitions.

Key Findings

Among 150 surveyed patients and caregivers, 59% reported receiving written discharge instructions. However, documentation of HF-specific self-care recommendations such as daily weight monitoring and adherence to a low-salt diet ranged narrowly between 15% and 41%. This gap indicates underemphasis on critical self-management practices in written communications. Although 87% of patients reported receiving a medication list, only 53% had this list reflected in the official discharge instructions, and active medication adherence support was documented in just 24% of cases. This discrepancy signals a disconnect between patient experience and formal documentation, posing risks for medication-related adverse events.

Follow-up care coordination demonstrated similar inconsistencies; 37% of respondents reported having a scheduled primary care appointment post-discharge, yet only 13% of the discharge instructions documented this information. The absence of standardized elements in discharge planning and the frequent reliance on verbal education were recurrent themes in qualitative interviews with SNF staff. Workforce limitations and nonstandardized discharge workflows were cited as substantial barriers to comprehensive and consistent patient preparation and communication. Staff emphasized that these operational constraints often result in variability in the quality and completeness of information transferred to patients and subsequent care providers.

Expert Commentary

This study highlights critical transitional care gaps during a vulnerable recovery period for older adults with HF. The discordance between patient-reported education and written discharge materials reflects systemic shortcomings in communication protocols and documentation standards within SNFs. Ensuring that discharge instructions comprehensively cover disease-specific self-care, medication reconciliation, and follow-up plans is pivotal to mitigate adverse events and reduce rehospitalization risk.

Current heart failure management guidelines stress the importance of multidisciplinary coordination and patient-centered education at discharge. However, the staffing challenges and workflow heterogeneity reported underscore the need for health system–level interventions, including dedicated transition teams and standardized discharge checklists tailored to HF. Moreover, leveraging health information technology for improved communication between SNFs, patients, caregivers, and outpatient providers may facilitate effective continuity of care.

Limitations of this study include its focus on nonprofit SNFs within a limited geographic area, potentially affecting generalizability. Future research should evaluate the impact of targeted interventions addressing these identified gaps on patient outcomes and healthcare utilization metrics.

Conclusion

The transition from skilled nursing facilities to home following heart failure hospitalization is marked by suboptimal communication, inconsistent self-care education, incomplete medication management, and inadequate follow-up coordination. These modifiable vulnerabilities present opportunities for quality improvement interventions aimed at standardizing discharge workflows and enhancing cross-setting communication. Structural and workforce challenges within SNFs must be addressed to sustain long-term improvements in transitional care quality and patient outcomes in this high-risk population.