Table 1.

Problems, Barriers, Targets, and Recommendations for Improving Heart Failure Care in Skilled Nursing Facilities

Factors Associated with Poor Outcomes for SNF Patients with HF	Problem Specifics	Barriers to Quality Improvement	Targets for Intervention	Recommendations
Patients	• Older • Multiple co-morbidities, • Functional and cognitive impairment	• Administrative pressure for timely hospital discharge • Lack of attention to patient goals of care and end of life preferences • Lack of evidence based treatment strategies	• Improved evaluation of readiness for hospital discharge • Patient centered care; Attention to geriatric and cardiology care issues • Underutilization of palliative care	• Coordinated multidisciplinary pre-discharge assessments • Investigation into geriatric based management options, consultation with cardiologist • Consultation to palliative care and hospice services
Transitions of Care	• Documentation deficits	• Lack of standardization • Unclear which components of care are most pertinent to SNF admission • Lack of HF specific information	• Identification of pertinent HF specific information • Standardization of discharge documentation • Addressing patient goals of care • Addressing social support structure	• Inclusion of physiologic targets, and changes and responses to medication regimen • Recommending laboratory monitoring, and weight management • Inclusion of advanced directives, health literacy • Designation of primary caregiver/decision maker • Required discharge summary from SNF providers to community providers • Document functional gains and NYHA class, HF symptoms at SNF discharge • Provision of HF specific discharge information to cardiologist/HF specialist
	• Communication deficits	• High clinical complexity • Inadequate HF training among SNF staff • Time constraints and volume of transfers limit participation in hand-offs • Lack of designated community PCP • Inability for frail cognitively impaired patients to participate in their own care.	• Inter-professional team communication of HF details • Establish designated communications personnel • Enhance mid-level or physician to physician hand-offs	• Include HF specific information in multidisciplinary transitional communications • Develop Inter-professional care plan • Designate select staff to communicate comprehensive discharge instructions role to select staff • Utilize a transitional coach for patients • Enhance caregiver involvement
	• Transitional Care Coordination	• Lack of SNF staff organizational structures • Lack of staff training in transitional care	• Develop of HF sensitive transitional care programs	• Incorporate HF specific clinical targets and patient goals into communications • Involving HF specialty provider in communication chain
Systems of Care	• Risk Prediction	• Lack of validated HF risk prediction models for SNF patients	• Develop and validate current risk prediction models for patients with HF in SNFs	• Include caregivers in HF transitional care • Use of one or all currently available risk prediction tools to guide general risk estimates until more specific risk models are available:   -HOSPITAL score45 – identifies risk of potentially avoidable 30-day readmissions in SNF patients, but not specific for HF patients   -Registry based risk prediction tool44 – identifies indicators of HF rehospitalization in one SNF, but not validated   -CORE risk calculator43 -predicts readmission risk of hospitalized HF patients, but not validated in SNF cohort
	• Disease Management Programs	• Lack of standardized protocols • Culture of SNF care not aligned with goals of post-acute patients with HF • Lack of outcomes data proving benefit of HF DMPs in SNFs	• Staff education to improve recognition and monitoring of at-risk patients • Development of DMPs tailored to SNF patient demographic • Further research and outcomes data on effects of SNF based HF DMPs	• Use of HF order sets to monitor clinical status and apply basic principles of HF management (i.e. dietary compliance and diuretic use) • Incorporate management for non-HF patients at risk for developing HF • Assess and manage comorbidities • Focus on HFpEF • Incorporation of geriatric principles into HF management strategies • Use the 2015 Scientific Statement on HF Management in SNFs13
	• Patient Monitoring	• Lack of standardized monitoring processes • Nuanced and unfamiliar triggers of HF exacerbation • Lack of control over patient choices and compliance • Nursing and nutrition service culture accustomed to improving hydration/ failure to thrive • Cognitive limitations in patients impairs symptom reporting	• Staff education specifically to monitor nuanced factors contributing to exacerbations in SNF patients with HF (i.e. atrial arrhythmias, infection, high sodium meals/snacks)	• Collective nursing effort to monitor at risk patients • Close monitoring of weights, diuretic needs, dietary choices, symptoms • Improved training on triggers for HF exacerbation in SNF HFpEF patients Notification to physician of changes in physiologic status • Monitoring status of comorbid illnesses
	• Timely interventions	• Lack of standardization of protocols for timely intervention specific to HF patients • Lack of staff training to administer interventions and/or IV medications	• Increased use of quality improvement interventions • Train on HF specific interventions, including IV medication administration • Compliance with CMS proposal for physician bedside encounter prior to hospital transfer	• Use of Interact II52 to assess clinical changes • Broaden assessment and interventions to incorporate HF issues • Redirect management strategy when interventions are not effective • Improve bedside availability of SNF based physicians • Use of specialty consultation when needed
Skilled Nursing Facility Characteristics	• Non-Modifiable	• Facility size • Profit status • Free standing vs. hospital based •Geographic location	• Improved awareness of outcomes and achievement of quality metrics associated with non-modifiable facility factors	• Mindful recommendation of SNFs with non-modifiable factors for high risk patients • Cautious selection of SNFs with higher quality ratings based on non-modifiable factors, (i.e. smaller, hospital based not for profit facilities)
	• Modifiable	• Lack of resources to improve SNF staffing availability and staff to • Cultures resistant to changing administrative or admitting practices • Misaligned incentives to admit healthy patients	• Improved NP/MD, RN, and PT/OT staffing availability • Increased preparedness for admission of high risk patients • Promoting a culture of change and com- mitment to excellence among staff • Improved administrative policies on staff education and team building • Building collaborative networks with hospitals and community providers	• Selection of SNFs for high risk patients with emphasis on quality of care • Administrative leadership investment in quality improvement • Motivate to establish partnerships with referral networks.

SNF, Skilled Nursing Facility; HF, Heart Failure; NYHA, New York Heart Association; PCP, Primary care provider; DMP, disease management program; HFpEF, Heart failure with preserved EF; IV, intravenous; CMS, Center for Medicare and Medicaid Services; NP, nurse practitioner; MD, Doctor of medicine; RN, registered nurse; PT, physical therapy; OT, occupational therapy.