Post-acute Care for Patients with Heart Failure

Abstract

Patients hospitalized for heart failure (HF) frequently require post-acute care (PAC) services after discharge. This review highlights recent updates on HF patient demographics, risk predictors for adverse outcomes, and management strategies for patients with HF in post-acute care settings, particularly within skilled nursing facilities (SNFs) and home health care (HHC). PAC is increasingly utilized for older patients who require ongoing intensive services in order to achieve physical or medical stability after a hospitalization for HF. Patients admitted to SNF and/or HHC frequently have multiple comorbid illnesses and suffer from functional and/or cognitive impairment. These patients are particularly vulnerable to adverse events, including rehospitalization or mortality. Deficits in transitional care, lack of standardized disease management protocols in PAC, and the higher complexity of comorbid illness in this population contribute to their poor outcomes. Legislative initiatives have emphasized improving the quality and efficiency of care delivery in PAC. Interventions that improve care transitions, delivery of care within SNFs, and patient education have shown promise in improving outcomes. Patients with HF in PAC have high medical acuity and need consistent and focused HF care to improve outcomes. Transitions between the hospital and PAC are a perilous time for these patients and new innovative practices of care are promising.