The Bridge Project: improving heart failure care in skilled nursing facilities

Area of Science:

• Gerontology
• Cardiology
• Healthcare Management

Background:

• High rehospitalization rates for heart failure (HF) patients underscore critical gaps in care transitions.
• Skilled nursing facilities (SNFs) are crucial for managing older adults with HF during care transitions.

Purpose of the Study:

• To assess the current state of HF management within SNFs, including patient identification, protocols, and staff expertise.
• To evaluate the effectiveness and acceptance of an educational program designed to enhance HF care provided by SNF staff.

Main Methods:

• Four SNFs participated in a two-year study, with two facilities involved each year.
• Disease management techniques were surveyed across disciplines, and staff knowledge/confidence in HF care was assessed pre- and post-training.

Main Results:

• Rehospitalization rates varied widely (18%-43%), with a consistent lack of HF patient identification and tracking across all participating SNFs.
• No SNFs had HF-specific disease management protocols, and staff demonstrated limited HF knowledge prior to the educational intervention.
• Post-training assessments showed significant improvements in staff knowledge and confidence regarding HF management.

Conclusions:

• The absence of systematic HF patient identification and tracking hinders effective care delivery in SNFs.
• Implementing HF-specific staff education is crucial for improving the quality of care and management of heart failure patients within SNFs.