Challenges and Opportunities in Implementing Heart Failure Guidelines in Skilled Nursing Facilities (SNFs)

Perraillon et al. (2022) highlight that heart failure (HF) management in skilled nursing facilities (SNFs) presents a complex challenge in the healthcare landscape. As the population ages and the prevalence of HF increases, SNFs play a crucial role in providing care for patients transitioning from acute care settings. However, implementing evidence-based HF guidelines in these facilities faces numerous obstacles. Bates et al. (2024) explore the challenges and opportunities in HF management within SNFs, addressing organizational, clinical, and communication barriers while highlighting potential strategies for improvement.

Manges et al. (2021) characterize the landscape of HF care in SNFs by high staff turnover, complex patient needs, and frequent transitions between care settings. These factors contribute to disruptions in care continuity and challenges in adhering to HF protocols. Additionally, Mukamel et al. (2023) note the growing prevalence of comorbidities, particularly dementia, among SNF residents further complicates care delivery. Rockwell et al. (2023) set the stage for a comprehensive examination of the current state of HF management in SNFs and the potential avenues for enhancing care quality and patient outcomes.

Skilled nursing facilities (SNFs) play a critical role in managing heart failure (HF), particularly for older adults transitioning from acute care settings. Despite advancements in evidence-based guidelines, significant barriers impede effective HF management in these environments. These challenges span organizational, clinical, communication, and implementation domains, often exacerbated by the complex needs of the patient population and systemic resource constraints. Addressing these issues requires a multifaceted approach that integrates staff education, standardized protocols, and tailored care strategies to improve outcomes and reduce hospital readmissions. ? SNFs frequently grapple with high turnover rates among nurses and certified nursing assistants, which disrupts continuity of care and undermines consistent adherence to HF protocols. Staff attrition creates knowledge gaps, as newly hired personnel may lack familiarity with facility-specific protocols or the nuances of HF management. For instance, daily weight monitoring—a cornerstone of HF care—often falters when staff changes occur, leading to delayed recognition of fluid overload.

Searle and Beehner (2023) asserted that residential care and assisted living provide housing and healthcare services for nearly one million individuals in the United States. Employee turnover in these facilities negatively impacts organizational efficiency and resident care results. The turnover of healthcare professionals can lead to substantial expenses, such as (Searle and Beehner, 2023) training and recruitment. Assisted living offers residents the option to maintain independence and receive assistance with daily living activities. The average age of residents in assisted living communities is 85, with 38% (Searle and Beehner, 2023) requiring assistance. The elderly population is expected to (Searle and Beehner, 2023) increase to over 20% by 2030. The healthcare industry faces significant negative costs from employee turnover, which can affect reputation, productivity, and effectiveness. Healthcare industry leaders must recognize employees as essential capital and identify factors affecting turnover. Searle and Beehner's (2023) study reviews assisted living facilities, their benefits, and employee turnover and provides suggestions for retention strategies for leaders in assisted living facilities.

Mukamel et al. (2023) conducted a comprehensive study on Alzheimer's disease and related dementias (ADRD) in US nursing homes between 2017 and 2019. The researchers found that over three million nursing home residents were diagnosed with ADRD during this period, highlighting the growing concern as the population ages and ADRD prevalence increases (Mukamel et al., 2023). Mukamel et al. (2023) study aimed to determine if residents with ADRD were concentrated in nursing homes where they formed the majority and to assess the implications for their quality of care and life. Using data from the Minimum Data Set and Medicare claims, the researchers discovered that residents with ADRD were dispersed throughout all nursing homes (Mukamel et al., 2023).

Fewer than half of these residents lived in facilities where ADRD patients accounted for 60-90 percent of the census (Mukamel et al., 2023). Interestingly, only facilities with over 90% of residents having ADRD appeared to offer better care (Mukamel et al., 2023). This finding raises concerns about the quality of care and life for the majority of residents with ADRD, suggesting a need for coordination between current National Institutes of Health dementia research initiatives and the Biden administration's policies to improve nursing home care (Mukamel et al., 2023). Mukamel et al. (2023) study utilized Minimum Data Set data to calculate various facility-level metrics, including the average daily percentage of patients with ADRD or cognitive impairment, residents receiving hospice care, and daily average age, sex, race, and case-mix index (Mukamel et al., 2023). The case-mix index, based on the Resource Utilization Groups-IV score, reflects the average acuity, functional, and cognitive impairment levels of residents and determines Medicare payment and, in some states, Medicaid payment (Mukamel et al., 2023).

Abraham et al. (2021) claimed that heart failure (HF) remained a significant global public health problem, with efforts to develop new approaches to improve functional status, quality of life, exercise tolerance, morbidity, and mortality. The focus of HF disease management has shifted from managing episodes of decompensation requiring hospitalization to achieving and maintaining stability in order to keep patients out of the hospital, a more proactive approach (Abraham et al., 2021). A holistic approach is needed, including managing underlying heart disease, comorbidities, social and psychological aspects of the disease, and managing haemodynamic/fluid status (Abraham et al., 2021). Assessment tools focused on measuring patient volume status, particularly on haemodynamic and/or pulmonary congestion, are essential for helping clinicians keep patients well and out of the hospital by avoiding episodes of volume retention (Abraham et al., 2021).

Abraham et al. (2021) demonstrated at least five prerequisites for successful heart failure monitoring technology: First, these tools should measure an appropriate signal, which is the underlying pathophysiology contributing to worsening HF symptoms and clinical events. Direct measurement of haemodynamic and/or pulmonary congestion, rather than assessment of their downstream consequences, may provide the best target and greatest opportunity for proactive intervention and avoidance of hospitalizations (Abraham et al., 2021). Second, sensors must be accurate, providing measurements that have been validated against gold standards such as the Swan–Ganz catheter in the case of haemodynamic pressure sensors or computed tomography (CT) in the case of lung fluid content assessment devices (Abraham et al., 2021). Third, the information provided must be directly actionable, in that we must understand the meaning of the information to know what an appropriate response is (Abraham et al., 2021). Fourth, an algorithm can be provided to guide clinicians on how to use the information provided by the technology and to adjust medical therapies when abnormal values are recorded (Abraham et al., 2021).

Currently, two available HF monitoring systems meet all five requirements for successful HF monitoring technologies: the implantable haemodynamic monitor—CardioMEMS HF System (Abbott, Sylmar, California), which is the only FDA approved system (Abraham et al., 2021) for outpatient PAP monitoring, and the non-invasive lung fluid monitor—ReDS System (Sensible Medical Innovations, Ltd., Netanya, Israel), which is FDA cleared for use in the United States (Abraham et al., 2021). Trials with new HF-monitor systems that meet all five proposed requirements are ongoing (Abraham et al., 2021). Increases in ventricular filling pressures in both diastolic and systolic HF patients occur weeks before HF hospitalization (Abraham et al., 2021). By targeting day-to-day maintenance of normal ventricular filling pressures, an implantable HF management system using ambulatory intracardiac or PAP monitoring may keep patients out of the hospital and reduce HF mortality (Abraham et al., 2021). Remote dielectric sensing readings can be helpful across the spectrum of HF states, from stable to decompensating to hospitalized to the post-discharge state, in various healthcare settings. Healthcare professionals at any level of experience can be trained to make accurate ReDS measurements (Abraham et al., 2021). Patients in SNFs often undergo multiple transitions between hospitals, rehabilitation centers, and home settings, complicating care coordination. During these transitions, critical HF-specific information—such as medication adjustments or baseline ejection fraction—is frequently omitted from discharge summaries.

For example, only 30% of SNF residents receive documentation detailing diuretic titration plans or sodium restriction targets after hospital discharge. This lack of standardized communication exacerbates readmission risks, particularly for patients with cognitive impairments who cannot self-advocate. Compounding this issue, SNFs often lack dedicated transitional care teams to reconcile medications or coordinate follow-up appointments, leaving patients vulnerable to post-discharge decompensation. Hirschman, McHugh, and Morgan (2023) indicated that over 6 million people are currently living with Alzheimer's disease and other dementias in the United States, with an estimated number expected to increase to 13 million by 2051. Dementia is the fifth leading cause of death and the only leading cause of death without effective disease-modifying treatments. People with dementia typically have at least three other conditions (79%), and nearly all people living with dementia (96%) have at least one or more additional chronic conditions (Hirschman, McHugh, and Morgan, 2023). Individuals living with dementia in the United States have more hospital stays and emergency department visits than individuals without dementia.

In 2018, the Alzheimer's Association released the Dementia Care Practice Recommendations (DCPR) to provide a framework that shifts the characterization of persons living with dementia and their caregivers from inevitable functional decline to one that characterizes the full spectrum of experiences, including emphasizing well-being and personhood (Hirschman, McHugh, and Morgan, 2023). The DCPR includes nine domains of quality dementia care, including person- and family-centered care; detection and diagnosis; assessment and care planning; medical management; information, education, and support; ongoing care for behavioral, psychological, and functional symptoms; staffing; supportive and therapeutic environments; and transitions and coordination of services (Hirschman, McHugh, and Morgan, 2023). To characterize and improve these domains in clinical practice, there is critical to identify measures that effectively capture the full range of the dementia experience within this new framework of care. Hirschman, McHugh, and Morgan's (2023) research focused on measures related to care transitions and the coordination of services. Effective transitional care and care coordination interventions can reduce or postpone care transitions for persons living with dementia (Hirschman, McHugh, and Morgan, 2023). Hirschman, McHugh, and Morgan (2023) contended that effective transitional care and care coordination interventions can reduce or postpone care transitions for persons with dementia. Recommendations include preparation and education about common transitions; complete and timely communication between, across, and within settings; evaluation of preferences and goals; interprofessional team collaboration; and initiating evidence-based care models (Hirschman, McHugh, and Morgan, 2023).

However, a gap remains in our knowledge of the measures available to evaluate care transitions and care coordination for persons with dementia and their caregivers (Hirschman, McHugh, and Morgan, 2023). To translate the DCPR into practice and provide effective transitional care and care coordination, researchers and clinicians need to understand the measures available to assess transitional care and care coordination and evaluate the quality of those measures according to the principles of the DCPR (e.g., person- and family-centeredness, accessibility, and consistency) (Hirschman, McHugh, and Morgan, 2023). Hirschman, McHugh, and Morgan (2023) presented that two instruments were used to assess transitional care or care coordination needs: the Johns Hopkins Dementia Care Needs Assessment (JHDCNA) from the Maximizing Independence at Home trials and unmet care needs assessment from the Partners in Dementia Care trials. Both instruments assess the needs of persons with dementia and their caregivers and can be incorporated into the care coordination plan. However, neither instrument explicitly incorporates strengths, and both are very time and resource-intensive to complete (Hirschman, McHugh, and Morgan, 2023). Hirschman, McHugh, and Morgan (2023) maintained that engagement potential is intended to identify individuals living with dementia who can engage with care coordination interventions. Hirschman, McHugh, and Morgan (2023) used a modified version of the Short Blessed Orientation-Memory-Concentration Test to identify individuals who are likely to be able to engage with care coordinators over the telephone.

Manges et al. (2021) argued that healthcare systems are increasingly seeking solutions to improve patient outcomes and align with financial incentives. The Bundled Payments for Care Improvement (BPCI) program holds hospitals responsible for costs associated with an episode of care triggered by a hospitalization, and hospital readmission accounts for a substantial proportion of overall episode costs (Manges et al., 2021). The newly implemented SNF Value-Based Purchasing programme leverages financial penalties on SNFs with elevated hospital readmission rates (Manges et al., 2021). However, best practices for reducing readmissions from SNFs are unclear, as successful transition of care interventions require significant investment of new personnel in SNFs and are unlikely to be scalable or sustainable (Manges et al., 2021). Manges et al. (2021) indicated that identifying what distinguishes high-performing hospitals and SNFs from low-performing hospitals might provide fruitful insights. However, there is a knowledge gap regarding the most effective mechanisms or care processes hospitals and SNFs use to prepare patients for the transition to SNF (Manges et al., 2021). This study aimed to observe and identify transitional care processes for patients transitioning in high-performing and low-performing hospitals and their most frequently affiliated SNF partners (Manges et al., 2021).

Manges et al. (2021) demonstrated that transitions from hospitals to SNFs are potentially different from discharges to home due to the patient population being discharged to SNF having a higher level of acuity and requiring higher engagement of caregivers and interprofessional team involvement (Manges et al., 2021). Transition-in-care frameworks focus on patient education and care coordination activities, but there are no best practice guidelines for SNF transitions. Manges et al. (2021) stated that clinicians and researchers could use these findings to identify new target points for redesigning care, develop high-impact interventions, and establish evidence-based guidelines to improve hospital-to-SNFF transitions.

Implementing heart failure (HF) guidelines in skilled nursing facilities (SNFs) remains a significant challenge, but also presents numerous opportunities for improvement. The complexities of managing HF in SNFs are compounded by high staff turnover, frequent care transitions, and the prevalence of comorbidities among residents. However, several promising approaches have emerged to address these challenges. Advancements in monitoring technologies, such as implantable hemodynamic monitors and non-invasive lung fluid monitors, offer new possibilities for proactive HF management. These tools can help clinicians maintain stability and reduce hospitalizations by providing actionable data on patients' fluid status. Furthermore, the development of comprehensive care frameworks, like the Dementia Care Practice Recommendations, emphasizes the importance of person-centered care and effective care coordination. These approaches can be adapted to improve HF management in SNFs, particularly for patients with cognitive impairments. To truly enhance HF care in SNFs, a multifaceted approach is necessary. This includes addressing staff retention, improving communication during care transitions, implementing standardized protocols, and leveraging new technologies.

?A study by Perraillon et al. (2022) identified several challenges in HF management in SNFs, including the need for better staff education and improved care coordination. Manges et al. (2021) found that high-performing hospital-SNF pairs demonstrated better transitional care processes, highlighting the importance of effective communication and collaboration. Additionally, Rockwell et al. (2023) reported positive outcomes from implementing a multimodal HF management protocol in an SNF, suggesting that standardized approaches can improve care quality. By focusing on these areas, SNFs can work towards providing more effective, consistent, and patient-centered HF care, ultimately improving outcomes and quality of life for this vulnerable population. The integration of virtual care programs and predictive analytics for rehospitalization risk assessment also shows promise in enhancing HF management in SNFs.?

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