Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study

Abstract

Objective: Discharge 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.

Design: Retrospective cohort study.

Setting and participants: All 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.

Results: Our 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.

Keywords: Readmission; heart failure; hospitalization; post-acute care; skilled nursing facility.

Figure 1:

Flow chart for cohort selection

Figure 2:

Violin plots of Readmission Densities by Length of Stay in SNF. We graphed out 30-day readmissions for patients based on SNF length of stay. On the horizontal axis are representative cohorts. The vertical axis represents the day after SNF discharge when readmission occurred. The density shows the relative number of 30-day readmissions that occurred on each day. This provides us a descriptive analysis of the timing of readmission. We qualitatively observed that proportion of readmissions appeared to be higher on days 0-3 after SNF discharge to home versus days 4-30 after SNF discharge to home We also qualitatively observed that readmission patterns appeared to be different for patients with a LOS of 1-6 days, 7-13 days, and 14-30 days, respectively. Depicted above are representative cohorts.

Figure 3:

Risk of first hospital readmission for 30 days after discharge from SNF to home following hospitalization for heart failure.