What are the criteria for discharge to a Skilled Nursing Facility (SNF) versus hospice care?

From the Guidelines

When deciding between discharge to a skilled nursing facility (SNF) versus hospice care, the primary consideration should be the patient's prognosis and goals of care, with SNF placement being appropriate for patients who need rehabilitation or skilled nursing care but have potential for improvement or stabilization, typically with a life expectancy beyond six months, as recommended by the American Heart Association and the Heart Failure Society of America 1. The decision between SNF and hospice care requires careful consideration of the patient's functional status, cognitive status, and goals of care, as well as honest conversations with the patient and family about prognosis, as emphasized in the recommendations for heart failure management in skilled nursing facilities 1. Some key factors to consider when making this decision include:

• The patient's life expectancy, with hospice care typically being reserved for patients with a terminal illness and life expectancy of six months or less
• The patient's need for rehabilitation or skilled nursing care, with SNF placement being more suitable for patients who require physical therapy, occupational therapy, wound care, or IV medication management
• The patient's goals of care, with SNF placement focusing on rehabilitation and eventual recovery or functional improvement, and hospice care focusing on comfort and quality of life
• The patient's functional and cognitive status, with tools like the Palliative Performance Scale being used to assess functional status and inform decision-making The American Heart Association and the Heart Failure Society of America recommend that discussions about goals of care and preferences for end-of-life care should be included in advance care planning at the time of admission to the SNF and whenever there is a change in health status and level of care 1. Additionally, the recommendations emphasize the importance of patient-centered, highly individualized care, with decisions being based on shared decision-making between the healthcare team and informed patients or family 1. Medicare covers both SNF and hospice care, but with different eligibility requirements, with SNF requiring a qualifying 3-day hospital stay and focusing on rehabilitation, and hospice requiring physician certification of terminal illness and the patient's agreement to forego curative treatments.

From the Research

Discharge Criteria for Skilled Nursing Facility (SNF) vs Hospice Care

The decision to discharge a patient to a Skilled Nursing Facility (SNF) or hospice care depends on various factors, including the patient's medical condition, functional abilities, and goals of care.

• The study 2 found that higher therapy intensity in SNFs was associated with shorter length of stay and greater improvement in functional independence, suggesting that SNFs may be more suitable for patients who require intensive rehabilitation.
• In contrast, hospice care is typically reserved for patients with terminal illnesses who have a limited life expectancy and are no longer seeking curative treatment.
• The study 3 highlighted the role of physical, occupational, and speech therapy in hospice care, focusing on patient empowerment and quality of life, rather than rehabilitation or cure.
• More recently, the study 4 emphasized the importance of physical therapy, occupational therapy, and speech language pathology in palliative care, including hospice settings, to improve patient outcomes and quality of life.
• The study 5 discussed the challenges of making end-of-life care decisions, including the risk of over-treatment or under-treatment, and the need to consider non-epistemic values and societal attitudes towards death.
• The study 6 emphasized the importance of clinical reasoning in medical decision-making, particularly in areas where evidence-based guidelines are limited or incomplete, which may be relevant to decisions about discharge to SNF or hospice care.