Disease management partnership with skilled nursing facility improves heart failure 30-day readmission rates

Abstract

Heart failure (HF) and HF readmissions have reached epidemic proportions and highlight the importance of care transitions. Nationally, about one-quarter of HF patients are discharged to a skilled nursing facility (SNF). Typically, patients discharged to a SNF are more vulnerable than those discharged to home. Not surprisingly, one-quarter of these patients are readmitted to acute care hospitals within 30 days. In York, Pennsylvania, these patterns of readmission from SNFs are similar. To illustrate, approximately 23% of HF patients discharged from York Hospital to a SNF are readmitted within 30 days. To address this problem, a multidisciplinary team was formed to design and evaluate a quality improvement pilot to decrease HF readmissions from SNFs.