Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure

Published:August 31, 2021DOI:



      Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP).


      This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate.

      Setting and Participants

      Patients with a primary hospital discharge diagnosis of HF discharged to SNF.


      Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level.


      Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11).

      Conclusions and Implications

      Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Allen L.A.
        • Hernandez A.F.
        • Peterson E.D.
        • et al.
        Discharge to a skilled nursing facility and subsequent clinical outcomes among older patients hospitalized for heart failure.
        Circ Heart Fail. 2011; 4: 293-300
        • Mor V.
        • Intrator O.
        • Feng Z.
        • Grabowski D.C.
        The revolving door of rehospitalization from skilled nursing facilities.
        Health Aff (Millwood). 2010; 29: 57-64
        • Toles M.
        • Anderson R.A.
        • Massing M.
        • et al.
        Restarting the cycle: Incidence and predictors of first acute care use after nursing home discharge.
        J Am Geriatr Soc. 2014; 62: 79-85
        • Weerahandi H.
        • Li L.
        • Bao H.
        • et al.
        Risk of readmission after discharge from skilled nursing facilities following heart failure hospitalization: A retrospective cohort study.
        J Am Med Dir Assoc. 2019; 20: 432-437
        • Boxer R.S.
        • Dolansky M.A.
        • Chaussee E.L.
        • et al.
        A randomized controlled trial of heart failure disease management vs usual care in skilled nursing facilities.
        J Am Med Dir Assoc. 2022; 23: 359-366
        • Centers for Medicare & Medicaid Services
        The Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP).
        2017 (Available at:)
        • Carnahan J.L.
        • Unroe K.T.
        • Torke A.M.
        Hospital readmission penalties: Coming soon to a nursing home near you!.
        J Am Geriatr Soc. 2016; 64: 614-618
        • Boxer R.S.
        • Dolansky M.A.
        • Bodnar C.A.
        • et al.
        A randomized trial of heart failure disease management in skilled nursing facilities: Design and rationale.
        J Am Med Dir Assoc. 2013; 14: 710.e5
        • Daddato A.E.
        • Dollar B.
        • Lum H.D.
        • et al.
        Identifying patient readmissions: Are our data sources misleading?.
        J Am Med Dir Assoc. 2019; 20: 1042-1044
        • Green C.P.
        • Porter C.B.
        • Bresnahan D.R.
        • Spertus J.A.
        Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: A new health status measure for heart failure.
        J Am Coll Cardiol. 2000; 35: 1245-1255
        • Heidenreich P.A.
        • Spertus J.A.
        • Jones P.G.
        • et al.
        Health status identifies heart failure outpatients at risk for hospitalization or death.
        J Am Coll Cardiol. 2006; 47: 752-756
        • Riegel B.
        • Lee C.S.
        • Dickson V.V.
        • Carlson B.
        An update on the self-care of heart failure index.
        J Cardiovasc Nurs. 2009; 24: 485-497
        • Feltner C.
        • Jones C.D.
        • Cene C.W.
        • et al.
        Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis.
        Ann Intern Med. 2014; 160: 774-784
        • Centers for Medicare & Medicaid Services
        Hospital Compare.
        (Available at:)
        Date: 2017
        Date accessed: September 12, 2018
        • Gupta A.
        • Allen L.A.
        • Bhatt D.L.
        • et al.
        Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure.
        JAMA Cardiol. 2018; 3: 44-53
        • Fonarow G.C.
        • Yancy C.W.
        • Heywood J.T.
        • ADHERE Scientific Advisory Committee, Study Group, and Investigators
        Adherence to heart failure quality-of-care indicators in US hospitals: Analysis of the ADHERE Registry.
        Arch Intern Med. 2005; 165: 1469-1477
        • Smith Jr., S.C.
        • Fonarow G.C.
        • Zhao D.
        Measuring and improving the quality of heart failure care globally.
        JAMA Netw Open. 2020; 3: e1918642
        • Kortebein P.
        Rehabilitation for hospital-associated deconditioning.
        Am J Phys Med Rehabil. 2009; 88: 66-77
        • Dolansky M.A.
        • Xu F.
        • Zullo M.
        • et al.
        Post-acute care services received by older adults following a cardiac event: A population-based analysis.
        J Cardiovasc Nurs. 2010; 25: 342-349
        • Manemann S.M.
        • Chamberlain A.M.
        • Boyd C.M.
        • et al.
        Multimorbidity in heart failure: Effect on outcomes.
        J Am Geriatr Soc. 2016; 64: 1469-1474
        • Krumholz H.M.
        Post-hospital syndrome—an acquired, transient condition of generalized risk.
        N Engl J Med. 2013; 368: 100-102

      Related Podcast

      March 25, 2022

      March 2022 Issue: COVID 19, Pragmatic and Clinical Trials, and Nursing Home Infections

      Host: Dr. Karl Steinberg. Featuring: Dr. Philip Sloane, Dr. Mallory Brown.                 Recorded: March 23, 2022.

      Loading ...