Skilled Nursing Facility-to-Home Transitions After Heart Failure Hospitalization: A Mixed-Methods Study of Communication, Self-Care, Medication, and Follow-Up.

backgroundSkilled nursing facilities (SNFs) play a critical role in postacute recovery for older adults with heart failure (HF), yet the transition from SNF to home remains a vulnerable and understudied phase of care. Although discharge guidelines emphasize clear communication, HF-specific self-care education, medication management, and follow-up coordination, little is known about how these practices are implemented during SNF-to-home transitions.

methodsWe conducted a convergent mixed-methods study across 4 nonprofit SNFs, integrating data from postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, and semi-structured staff interviews. Eligible patients were Medicare beneficiaries aged ≥65 years discharged from SNF to home following HF hospitalization, with SNF stays ≤60 days. Quantitative data were analyzed using descriptive statistics, while qualitative data underwent thematic and directed content analysis. Findings were triangulated across data sources to identify key challenges and actionable strategies.

resultsAmong 150 respondents, 59% reported receiving written discharge instructions; however, HF-specific self-care elements (eg, daily weight monitoring, low salt diet) were documented in only 15% to 41% of instructions. Although 87% reported receiving a medication list, only 53% had it reflected in the discharge instructions, and adherence support was infrequently addressed (24%). Follow-up coordination was similarly discordant: 37% of respondents reported a scheduled primary care appointment, compared with 13% documented in discharge instructions. Staff interviews revealed nonstandardized discharge workflows, workforce constraints, and reliance on verbal education, contributing to variability in patient preparation and communication across care settings.

conclusionsSNF-to-home transitions after HF hospitalization are marked by discordance between patient-reported education and written documentation, as well as inconsistent medication and follow-up coordination. These gaps represent modifiable vulnerabilities during a high-risk recovery period. Standardized HF-focused discharge workflows and strengthened cross-setting communication may improve transitional care, while long-term solutions must address structural and workforce constraints.