Study: Heart Failure Patients at Greatest Readmission Risk Immediately After SNF Discharge to Home

April 24, 2019

Patients with heart failure who are discharged home after a skilled nursing facility (SNF) stay are at greatest risk for readmission in the first two days, according to a study in the April issue of JAMDA. However, this risk is lessened with longer SNF stays.

In “Risk of Readmission after Discharge from Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study,” the authors followed more than 60,000 heart failure patients for 30 days following SNF discharge. They classified patients by length of stay: 1-6 days, 7-13 days, and 14-30 days. They found that 16,333 (24.2%) were readmitted to the SNF within 30 days. The authors determined that the risk for readmission was 2-4 times higher immediately after SNF-to-home discharge, compared to later time periods; this early admission risk dropped by half for patients with SNF stays of 1-2 weeks compared with shorter stays.

The authors noted that disruption in care continuity when patients are transferred from the SNF to home may be an important factor in the heightened risk for readmission. They suggested that to reduce this risk, “patients discharged from the SNF may benefit from discharge planning since, during a SNF stay, medications may be started or adjusted, diets may be monitored, and lab tests may be obtained, which may need post-SNF discharge follow up.” The authors further observed that “studies on discharge practices have demonstrated the effectiveness of … instructions and early outpatient physician follow up after hospital discharge.”

The significance of identifying best practices for heart failure management in SNFs “will become increasingly evident,” the authors observed, especially since this condition is a chronic problem that requires ongoing disease management. They also stressed the importance of identifying high-risk patients and optimizing treatments, interventions, and services as they move through the care continuum.

This study was conducted by researchers at the Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY; Center for Outcomes Research & Evaluation, Yale University, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY; and Clover Health, Jersey City, NJ.

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JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit for more information.

About the Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit for more information.