Himali Weerahandi, M.D.

Post-acute heart failure patients admitted to a skilled nursing facility have better outcomes — including lower rates of rehospitalization — with a standardized, nurse-led disease management program, according to a new study.

Identifying residents most at risk of rehospitalization due to heart failure complications may not only maximize program benefits, but help operators avoid Medicare part A claims penalties incurred with high 30-day readmission rates, researchers say.

More than 670 patients were enrolled in the study from 37 SNFs, most of which were for-profit. Patients were cared for by 59 physicians and practices within the Denver metropolitan area. They were eligible for inclusion if they had a diagnosis of heart failure, regardless of ejection fraction, and after admission to an SNF following acute care for any cause. Patients were not eligible if they had a life-limiting condition with expected mortality of six months or less, if they were admitted to the hospital from a long-term care facility, or were on hemodialysis. 

RN in charge

A registered nurse delivered the heart failure program, which was standardized for skilled nursing facility care along heart failure practice guidelines and performance measures.  The nurse advocate visited study participants three times over seven days and also scheduled post-discharge check-ins. 

The intervention included documentation of ejection fraction in the SNF chart; medication titration recommendations, patient symptom and activity assessment; patient weight over time; and a low-sodium dietary recommendation, patient and caregiver education and seven-day post-discharge follow-up.

A control group received usual care, with data collected for the same measures as the heart failure program group.


Sixty days after skilled nursing home admission, patients in the heart failure program had a lower composite rate of rehospitalization, emergency department visits or mortality when compared with those who received usual care — at 30% and 52% respectively, reported Himali Weerahandi M.D., MPH, of the New York University Grossman School of Medicine and NYU Langone Health. 

Earlier, at 30 days, the rate of these composite events was 18% among the heart failure program participants vs. 31% in the usual care group.

Notably, heart failure program recipients also had a lower rate of adverse events after SNF discharge. This indicates that the changes persisted, Weerahandi wrote. In addition, there were fewer heart failure-related events in the program intervention group, whereas rates of other adverse health events were similar between the groups. This result suggests that heart failure disease management can be an effective approach to improve outcomes, Weerahandi and colleagues wrote.

Some of the benefits may have derived from the structured educational component of the intervention, they said. 

“It is important for SNFs to strategically target patients at risk for rehospitalization and apply effective approaches to reduce this risk as the Centers for Medicare & Medicaid Services SNF Value-Based Purchasing Program has financial ramifications: SNFs with high 30-day rehospitalization rates face penalties of up to 2% on their Medicare Part A claims,” they concluded.

The study was published in JAMDA.