ArticleJournal of the American Medical Directors Association2019
Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study.
Article in Journal of the American Medical Directors Association, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
10 citing papers in PubMed.
- Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial.Journal of the American Geriatrics Society · 2023Trial
- Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure.Journal of the American Medical Directors Association · 2022Trial
- Skilled Nursing Facility-to-Home Transitions After Heart Failure Hospitalization: A Mixed-Methods Study of Communication, Self-Care, Medication, and Follow-Up.Circulation. Heart failure · 2026Article
- Staffing of Qualified Social Workers and Nursing Home Quality of Care.JAMA network open · 2026Article
- Healthcare utilization and costs in the first two years after heart failure diagnosis: an observational study by phenotype in southwestern Sweden.BMC health services research · 2026Observational
- Hospital health information exchange participation and heart failure discharges to skilled nursing facilities: a cohort study.BMC health services research · 2025Article
- The Effects of Post-Acute Care in Patients with Heart Failure in Taiwan: A Single Center Experience.Acta Cardiologica Sinica · 2023Article
- Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States.The Journal of surgical research · 2022Article
- Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care.Journal of the American Medical Directors Association · 2021Article
- Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization.Journal of the American Geriatrics Society · 2020Article
Corrections and comments
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Authors and funding
9 authors.
Funding
Abstract
objectiveDischarge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.
designRetrospective cohort study. SETTING AND
participantsAll Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES: Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge.
resultsOur study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS: The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.
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