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A randomized trial of heart failure disease management in skilled nursing facilities: design and rationale.


ABSTRACT: Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults.The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days post-SNF admission. The trial is a randomized cluster trial to be conducted in 12 for-profit SNF in the greater Cleveland area. The study population is inclusive of patients with HF regardless of ejection fraction but excludes those patients on dialysis and with a life expectancy of 6 months or less. The HF-DMP includes 7 elements considered standard of care for patients with HF documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7-day follow-up appointment post-SNF discharge, and patient education. The HF-DMP is conducted by a research nurse tasked with adhering to each element of the program and regularly audited to maintain fidelity of the program. Additional outcomes include health status, self-care management, and discharge destination.The SNF-Connect Trial is the first trial of its kind to assess if a HF-DMP will improve outcomes for patients in SNFs. This trial will provide evidence on the effectiveness of HF-DMP to improve outcomes for older frail HF patients undergoing postacute rehabilitation.

SUBMITTER: Boxer RS 

PROVIDER: S-EPMC3904547 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature

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A randomized trial of heart failure disease management in skilled nursing facilities: design and rationale.

Boxer Rebecca S RS   Dolansky Mary A MA   Bodnar Christine A CA   Singer Mendel E ME   Albert Jeffery M JM   Gravenstein Stefan S  

Journal of the American Medical Directors Association 20130718 9


<h4>Background</h4>Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults.<h4>Methods and anticipated results</h4>The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days  ...[more]

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