Three decades ago, when the discharge based prospective payment system of 1984 gave hospitals an incentive to significantly reduce inpatient length of stay, older adults were being discharged more quickly and in less stable condition, i.e. “quicker and sicker,” and utilization of post-acute care services after hospital discharge for these patients increased. Reimbursement incentives and improvements in technology led to a dynamic change in skilled nursing facilities (SNFs), and the rise of what is often referred to as the “subacute SNF.” Older patients with cardiovascular disease are increasingly discharged to SNFs, and now roughly 1 in 4 older patients hospitalized for heart failure (HF) are discharged to SNF level care for ongoing medical therapy and/or restorative rehabilitation. Patients selected for SNF admission are older, more frail, have higher numbers of comorbidities, and more significant functional and cognitive limitations.
When the Affordable Care Act enacted legislation penalizing hospitals for HF readmissions, I saw an opportunity to develop a practice providing cardiovascular care to vulnerable HF patients admitted to SNFs. The clinical focus on geriatric cardiology, as well as the opportunity to help facilities develop programs and educate their staff about HF management were very compelling. Since starting my practice almost three years ago, not a day has passed without an opportunity for growth and learning.
In my current practice I consult for sixteen SNFs, and I have come to synthesize that the challenges of HF care provision in this setting stem from three broad elements: 1) the patients, who often have advanced disease; 2) the systems, which are not yet optimized for transitional care (hospital to SNF or SNF to home); and 3) the facilities, which lag hospitals in their development of disease management programs and staff education. Perhaps more importantly, I have grown to understand that the practice of post-acute cardiology requires a unique blend of outpatient and inpatient cardiac care, general cardiology, geriatric medicine, and medical and ancillary care provision (i.e. physical and occupational therapy).
Practicing post-acute cardiology provides a direct window into the clinical and functional challenges patients face after an acute hospitalization, and has been directly illustrative of why older HF patients are at such high risk for readmission. Described by Dr. Krumholz as “post-hospitalization syndrome,” this period recovery is often accompanied by changes in cognitive status or delirium, relatively poor nutritional intake, disturbed sleep patterns, emotional and psychosocial stress, frailty exacerbations, and impaired coordination and deconditioning. It is in this vulnerable period that we ask patients in subacute rehab to recover to their prior level of functioning within 30 days, lest they lose their therapy coverage afforded by their insurance. I have learned all too well that post-acute cardiology care requires striking a fine balance between optimal medical management of an acute cardiac condition, and preserving functional and cognitive ability to enhance recovery. After being disheartened when patients failed to meet their restorative goals because of side effects of intensified cardiovascular medications such as prohibitive orthostasis or fatigue, I learned that optimizing cardiovascular recovery can be incompatible with optimizing functionality and recovery in immediate post-acute care. Knowing which goals of care to prioritize remains a developing medical art.
While the cardiology and post-acute care community has responded to the needs of the growing HF population in SNFs by recently publishing scientific statements and clinical practice guidelines for the care of the SNF HF patient, evidence based recommendations are desperately lacking. I recently published a review discussing some of the challenges and targets for intervention in the care of HF patients in SNFs with colleagues similarly dedicated to the care of these unique individuals. Amidst emerging legislation poised to penalize SNFs for higher than average 30 day readmissions next year, we emphasized in this article that SNFs will increasingly need to invest in the quality of care they deliver. As demands grow, perhaps SNFs will need to allocate their limited resources to subspecialized areas, and those that chose to invest in optimizing HF care might qualify to distinguish themselves as “Heart Failure Ready.” Patients, providers, and hospitals alike could perhaps benefit from this means of guidance in selecting appropriate post-acute facilities to meet their care needs.
The future of HF care in SNFs is a moving target and many changes are sure to come. I suspect that as the SNF patient becomes even more complex, the presence of cardiovascular specialists, now negligible, will grow. From the perspective of a SNF geriatrician, input from specialists with a historical focus on aggressive single disease management may not be aligned with goals of care for the complex SNF patient with multiple comorbidities; SNF specialists will therefore need to heed to geriatric principles of care, the importance of functional as well as clinical outcomes, and an understanding of cardiovascular disease within the context of aging, multimorbidity, and frailty. Amidst the vast unknown, one thing is certain – more research to define the optimal care for the post-acute cardiology patient is desperately needed.
By: Nicole Orr, MD