Skilled nursing facility-to-home transitions after heart failure hospitalization showed significant discordance, with HF-specific self-care elements documented in only 15% to 41% of instructions.
Observational (n=150)
Yes
SNF-to-home transitions for older adults with heart failure are characterized by significant discordance between patient-reported education and written documentation, highlighting the need for standardized discharge workflows.
BACKGROUND: Skilled nursing facilities (SNFs) play a critical role in postacute recovery for older adults with heart failure (HF), yet the transition from SNF to home remains a vulnerable and understudied phase of care. Although discharge guidelines emphasize clear communication, HF-specific self-care education, medication management, and follow-up coordination, little is known about how these practices are implemented during SNF-to-home transitions. METHODS: We conducted a convergent mixed-methods study across 4 nonprofit SNFs, integrating data from postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, and semi-structured staff interviews. Eligible patients were Medicare beneficiaries aged ≥65 years discharged from SNF to home following HF hospitalization, with SNF stays ≤60 days. Quantitative data were analyzed using descriptive statistics, while qualitative data underwent thematic and directed content analysis. Findings were triangulated across data sources to identify key challenges and actionable strategies. RESULTS: Among 150 respondents, 59% reported receiving written discharge instructions; however, HF-specific self-care elements (eg, daily weight monitoring, low salt diet) were documented in only 15% to 41% of instructions. Although 87% reported receiving a medication list, only 53% had it reflected in the discharge instructions, and adherence support was infrequently addressed (24%). Follow-up coordination was similarly discordant: 37% of respondents reported a scheduled primary care appointment, compared with 13% documented in discharge instructions. Staff interviews revealed nonstandardized discharge workflows, workforce constraints, and reliance on verbal education, contributing to variability in patient preparation and communication across care settings. CONCLUSIONS: 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.
Weerahandi et al. (Tue,) conducted a observational in Heart failure (n=150). Skilled nursing facility-to-home transition was evaluated on Receipt and documentation of discharge instructions, medication lists, and follow-up coordination. Skilled nursing facility-to-home transitions after heart failure hospitalization showed significant discordance, with HF-specific self-care elements documented in only 15% to 41% of instructions.