Comprehensive Approach to Skilled Nursing Facility Patient Care
The best approach to care for patients in Skilled Nursing Facilities (SNFs) requires implementing a structured interdisciplinary care model with comprehensive assessment, individualized care planning, and regular monitoring to improve survival, reduce hospitalizations, and enhance quality of life. 1
Understanding SNF Patient Categories
SNF patients typically fall into three distinct groups, each requiring tailored approaches:
- Rehabilitation Group: Patients recently discharged from hospital with the goal to recover function and return home after several weeks of skilled care 1
- Uncertain Prognosis Group: Patients discharged with complications, frailty, or multiple comorbidities, whose recovery and final disposition remain uncertain 1
- Long-Term Group: Residents with frailty and dependency expected to remain in the SNF until death 1
Core Components of Effective SNF Care
1. Comprehensive Assessment and Monitoring
- Conduct thorough initial assessment of physical, cognitive, emotional, and social status to determine necessary therapeutic interventions 1
- Implement careful surveillance for common complications including infections, electrolyte imbalances, and mental status changes, which are frequent causes of rehospitalization 1
- Establish regular monitoring protocols for vital signs, weight, and symptoms specific to underlying conditions 1
- Perform falls risk assessment with tailored prevention strategies, as falls represent a major health risk in SNF settings 2, 3
2. Interdisciplinary Team Approach
- Utilize a collaborative team including physicians, nurses, rehabilitation specialists, social workers, dietitians, and pharmacists 4, 5
- Hold regular interdisciplinary team meetings to coordinate care and update treatment plans 4
- Ensure clear communication between hospital and SNF teams during transitions of care to maintain continuity 4
- Implement higher RN staffing ratios when possible, as this has been shown to reduce hospitalization rates for longer-stay patients 1
3. Medication Management
- Review medication regimens regularly to identify potential interactions, inappropriate prescribing, and opportunities for optimization 6
- Ensure proper documentation of indications for all medications to comply with SNF pharmacy regulations 6
- Monitor for medication side effects and adjust dosages as needed, particularly for high-risk medications 6
- Implement protocols for medication reconciliation during transitions of care 1
4. Disease-Specific Management
- For heart failure patients, focus on monitoring for congestion, electrolyte imbalances, and early treatment of infections 1
- Tailor medication approaches based on patient category (rehabilitation, uncertain prognosis, or long-term) 1
- Implement dietary modifications appropriate to underlying conditions, such as sodium restriction for heart failure 1
- Establish protocols for diuretic dosage adjustment to maintain euvolemia while minimizing electrolyte disturbances 7
5. Quality Improvement Initiatives
- Implement chart audit and feedback systems to improve care processes 1
- Use reminder systems for specific medications or tests, and clinical decision support tools 1
- Establish quality measures that address both process and outcome metrics 1
- Provide intensive educational and behavioral interventions for staff to maximize guideline adherence 1
Special Considerations
Palliative Care Integration
- Discuss and document advance care preferences at admission and during significant clinical changes 1
- Implement palliative care approaches for symptom management alongside disease-directed treatments 1
- Consider hospice referral for appropriate patients with end-stage conditions 1
- Utilize transportable physician orders for life-sustaining treatment (POLST) forms 1
Fall Prevention
- Implement comprehensive structured individual assessment with specific safety recommendations 2
- Address environmental hazards, wheelchair use, psychotropic drug use, and transfer/ambulation techniques 2
- Provide staff education on fall prevention strategies and patient supervision 8
- Consider alternatives to continuous patient supervision when appropriate 8
Staff Education and Training
- Provide education on common conditions seen in SNF settings, including heart failure, diabetes, and dementia 1
- Train staff on proper assessment techniques, medication administration, and recognition of acute changes 1
- Educate on signs and symptoms requiring urgent intervention or transfer to acute care 1
- Implement multifactorial interventions targeting different barriers to change 1
Common Pitfalls and How to Avoid Them
Pitfall: Treating SNF care as simply an extension of hospital care without recognizing unique needs and constraints 1
- Solution: Develop SNF-specific protocols and quality measures that account for the complexity of care, multiple comorbidities, and resource limitations 1
Pitfall: Inadequate transitions of care leading to medication errors and missed follow-up 4
- Solution: Implement structured handoff procedures and ensure complete information transfer between care settings 4
Pitfall: Viewing falls as inevitable rather than preventable events 2
- Solution: Implement structured safety programs with individualized interventions that have been shown to reduce recurrent falls by up to 19% 2
Pitfall: Focusing solely on disease management without addressing functional status and quality of life 1
- Solution: Incorporate rehabilitation, social support, and quality of life measures into care planning 1