What is the ideal follow-up plan of care after discharge from skilled nursing (SNF)?

Ideal Follow-Up Plan of Care After Discharge from Skilled Nursing Facility

The ideal follow-up plan after discharge from a skilled nursing facility should include a comprehensive care transition with a follow-up appointment with the patient's provider within 7 days of discharge, assessment of functional status within 30 days, and appropriate referrals for ongoing care needs. 1

Key Components of Post-SNF Discharge Care

Immediate Follow-Up Appointments

• Schedule a follow-up appointment with the patient's primary provider within 7 days of SNF discharge to ensure continuity of care and prevent gaps in treatment 1
• For stroke patients, arrange formal assessment of mobility, activities of daily living (ADL), and communication/cognition by appropriate clinicians within 30 days of discharge 1
• For heart failure patients, schedule follow-up with the heart failure specialist within 7 days as this provides an important link back to community care 1

Comprehensive Care Transition Documentation

• Ensure bidirectional verbal and written communication between the SNF and receiving providers that includes:
  • Essential clinical data (diagnoses, vital signs, lab values, physical assessment findings) 1
  • Important decisions/events during the SNF stay (response to therapy, cognitive status, adverse events) 1
  • Medication list with documentation of any medication sensitivities and responses 1
  • Plan of care for the first 30 days post-discharge 1
  • Patient/family education provided and their understanding of the plan 1

Individualized Care Planning

• Develop a tailored exercise and fitness program for patients returning home to enhance cardiorespiratory fitness and reduce risk of readmission 1
• Assess self-management capabilities (patient, family member, or other care providers) and make appropriate referrals for home health care if needed 1
• For patients with anticipated limited life expectancy, consider hospice referral for palliation 1

Specific Follow-Up Requirements by Condition

For Stroke Patients

• Arrange formal assessment of ADL and instrumental ADL (IADL) status directly related to the discharge living setting 1
• Schedule follow-up on communication abilities and functional mobility within 30 days 1
• Provide ongoing support for caregivers, which has been shown to favorably affect both stroke survivor and caregiver outcomes 1
• Develop an individually tailored exercise program to enhance cardiorespiratory fitness 1

For Heart Failure Patients

• Monitor for signs of congestion, electrolyte imbalances, infections, and altered mental status as these are common reasons for rehospitalization 1
• Schedule a 7-day follow-up appointment with the heart failure provider 1
• Establish target weight, heart rate, and blood pressure goals 1
• Clearly identify who will be managing the heart failure care (cardiology, primary care, or other) 1

Caregiver Support and Education

• Assess caregiver needs and concerns from their perspective 1
• Provide caregivers with information about support groups, home help options, and rehabilitation resources 1
• Maintain contact with family caregivers after discharge (at 1,4,6, and 12 months) 1
• Encourage caregivers to participate in therapy sessions to learn what the patient can do 1

Preventing Readmissions

• Implement careful surveillance for infections, electrolyte imbalances, and mental status disturbances, which are common causes of readmission 1, 2
• Ensure proper medication reconciliation to prevent adverse drug events 1
• Provide clear instructions on warning signs that require medical attention 1
• Consider using quality improvement tools like INTERACT (Interventions to Reduce Acute Care Transfers) to manage acute changes in patient conditions 1

Common Pitfalls to Avoid

• Inadequate communication between facilities can lead to adverse events, increased costs, and increased length of stay 1
• Lack of follow-up appointments within 7 days may result in care gaps and potential readmissions 1
• Insufficient caregiver education and support can lead to poor outcomes and increased caregiver strain 1
• Failure to assess functional status within 30 days may miss opportunities for intervention 1
• Discharge to home with home health care without proper planning may be associated with higher rates of readmission compared to SNF care 3

By implementing this comprehensive follow-up plan after SNF discharge, healthcare providers can help ensure continuity of care, prevent readmissions, and improve patient outcomes while supporting caregivers in their essential role.