Risk of Readmission after Discharge from Skilled Nursing Facilities Following Heart Failure Hospitalization

Discharge to skilled nursing facilities (SNF) is common in patients with heart failure (HF), occurring in 1 in 5 Medicare beneficiaries after HF admission. While there have been epidemiological studies examining readmission and mortality directly from SNF, what is not known is whether the specific transition from SNF to home is risky for patients with HF.

Our objective for this study was to determine timing of readmissions within 30 days among patients first discharged to a skilled nursing facilities (SNF) after heart failure hospitalization who are subsequently discharged home.

We performed a retrospective cohort study of all Medicare fee-for-service (FFS) patients 65 and older admitted from July 2012- June 2015 with a principal discharge diagnosis of HF with SNF stays of 30 days or less following discharge from a heart failure hospitalization. Patients were followed for 30 days following discharge from SNF. We categorized patients based on SNF length of stay (LOS): group 1: 1-6 days, group 2: 7-13 days, group 3: 14-30 days. We then fit a piecewise exponential model with the outcome as time to readmission after discharge from SNF for each group. Our event of interest was unplanned readmission; death and planned readmissions were considered as competing risks. Our model examined two different time intervals following discharge from SNF: 0-3 days post SNF discharge and 4-30 days post SNF discharge. We estimated the relative risk of readmission for each time interval.

Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home (median age, 84 years [IQR; 78-89]; female, 61.0%); 13,257 (19.2%) were discharged with home care, 54,328 (80.4%) without. Median length of SNF admission was 17 days (IQR; 11-22). In total, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge; median time to readmission was 9 days (IQR; 3-18). The hazard rate of readmission for each group was significantly increased on days 0-3 after discharge from SNF (group 1, 0.0776 [0.0498-0.1072]; group 2, 0.0292 [0.021-0.0386]; group 3, 0.0164 [0.0133-0.0196]) compared to days 4-30 after discharge from SNF (group 1, 0.0194 [0.0124-0.0267]; group 2, 0.0129 [0.0093-0.0170]; group 3, 0.0100 [0.0082-0.0120]). In addition, the hazard rate of readmission during the first 0-3 days after discharge from SNF decreased as the LOS in SNF increased.

In conclusion, the readmission risk after SNF discharge following HF hospitalization is highest during the first six days home. SNF LOS also has an effect on readmission risk immediately after SNF discharge; patients with a longer LOS in SNF were less likely to be readmitted in the first 3 days after SNF discharge.

Innovative health care delivery models such as Accountable Care Organizations must consider transitions across different care settings in order to improve health care quality. The transition from SNF to home after heart failure hospitalization is associated with a risk of hospital readmission. Further work should examine if discharge practices used in hospitals could improve the transition from SNF to home.