How to manage patients with multiple comorbidities in a skilled nursing facility (SNF) after hospital discharge?

Managing Patients with Multiple Comorbidities in Skilled Nursing Facilities After Hospital Discharge

Categorize your recently hospitalized SNF patients into three distinct groups—rehabilitation, uncertain prognosis, or long-term—and tailor your management intensity, medication dosing, and goals of care accordingly, as this framework directly addresses the complexity of multimorbidity in the post-acute SNF setting. 1

Patient Categorization Framework

The American Heart Association provides a critical framework for SNF patients that you must apply immediately upon admission 1:

• Rehabilitation Group: Patients expected to recover independent function and return home after several weeks. These patients warrant full guideline-directed medical therapy with individualized titration 1

• Uncertain Prognosis Group: Patients discharged with complications, frailty, or multiple comorbidities where recovery is uncertain. Use lower medication doses and avoid hypotension 1

• Long-Term Group: Frail, dependent residents expected to remain in SNF until death. Prioritize symptom management and quality of life over aggressive titration 1

Critical Recognition of Multimorbidity Burden

Understand that almost 70% of SNF patients with heart failure have ≥3 noncardiac comorbidities, and 40% have ≥5 comorbidities 1. This massive comorbidity burden confounds patient assessment, reduces tolerance of medical therapies, and increases mortality 1.

Immediate Assessment Priorities

Upon SNF admission, systematically evaluate 1:

• Functional status: Only 30% of patients with new ADL disabilities (bathing, dressing, toileting, transferring, continence, feeding) will return to prior functioning 1

• Frailty markers: Assess nutrition/body weight, muscle strength, mobility, activity tolerance, and cognition—frailty strongly correlates with poor outcomes and medication intolerance 1

• Cognitive impairment: Directly impacts medication adherence and self-management capacity 1

• Goals of care: Clarify goals for all SNF residents immediately, as this determines treatment intensity 1

Medication Management Strategy

For patients with multiple comorbidities, start with lower doses and titrate cautiously, particularly avoiding hypotension which is poorly tolerated in frail SNF residents. 1

Specific Medication Approach by Patient Group:

Rehabilitation Group 1:

• ACE inhibitors/ARBs: Yes for HFrEF, individualize titration, avoid low systolic blood pressure
• Beta-blockers: Yes for HFrEF, as tolerated by blood pressure, heart rate, and fatigue
• Diuretics: Yes to achieve euvolemia

Uncertain Prognosis Group 1:

• ACE inhibitors/ARBs: Yes for HFrEF, but low dose preferable, avoid low systolic blood pressure
• Beta-blockers: Yes for HFrEF, as tolerated by blood pressure, heart rate, and fatigue
• Mineralocorticoid receptor antagonists: Avoid if eGFR <30 mL/min/m²

Long-Term Group 1:

• ACE inhibitors/ARBs: Yes for HFrEF, low dose preferable, avoid low systolic blood pressure
• All interventions should be individualized based on symptom burden and quality of life

Medication Reconciliation

Implement pharmacist-driven medication reconciliation at the time of hospital-to-SNF transfer, as this intervention reduces 30-day readmissions by 29% 2.

Common Precipitants of Decompensation in Multimorbid SNF Patients

Monitor vigilantly for these specific triggers 1:

• Infections: Pneumonia, sepsis, urinary tract infections are the most common precipitants 1
• Medication errors: Provider/system factors including medication reconciliation errors 1
• Dietary sodium excess and excess fluid intake 1
• Anemia and renal insufficiency (eGFR <30 mL/min) 1
• Arrhythmias: Especially atrial fibrillation and bradycardia 1
• Iatrogenic causes: NSAIDs, glucocorticoids, calcium channel blockers, even ophthalmic beta-blockers 1

Interdisciplinary Team Approach

Establish an interdisciplinary team including nurse practitioners, pharmacists, and SNF nursing staff with structured communication protocols. 2

The Enhanced Care Program model demonstrates that coordinated interdisciplinary teams reduce 30-day readmissions from 23.0% to 17.2% (29% lower odds after adjustment) 2. This requires 2:

• Nurse practitioners participating directly in SNF patient care
• Pharmacist-driven medication reconciliation
• Educational in-services for SNF nursing staff
• Collaboration with community physicians

Quality Improvement Implementation

Do not simply disseminate guidelines—this approach fails in SNF settings. 1 Instead, implement 1:

• Chart audit and feedback systems with results shared with providers 1
• Clinical decision support tools with reminders for specific medications or tests 1
• Local opinion leaders or HF experts to guide care 1
• Intensive educational and behavioral interventions for patients and caregivers (Class I recommendation) 1

Multifactorial interventions targeting different barriers simultaneously are more successful than isolated efforts 1.

Monitoring Strategy

Establish protocols for 3:

• Regular potassium monitoring in high-risk patients (those with kidney disease, heart failure, or on ACE inhibitors/ARBs/potassium-sparing diuretics) 3
• Diuretic dosage adjustment protocols to maintain euvolemia while minimizing electrolyte disturbances 3
• Daily assessment of patient status including weight, vital signs, and volume status 1

Care Transitions and Follow-Up

Schedule follow-up with the primary provider within 7 days of SNF discharge 4. Ensure bidirectional verbal and written communication between SNF and receiving providers that includes 4:

• Essential clinical data
• Important decisions/events during SNF stay
• Complete medication list
• Plan of care
• Patient/family education provided

Critical Pitfalls to Avoid

• Aggressive medication titration in frail patients: Use lower doses in uncertain prognosis and long-term groups to avoid hypotension and falls 1

• Ignoring functional status: Assess gross motor coordination, manual dexterity, cognitive function, and weight loss—these predict successful transition home 1

• Inadequate surveillance for infections: These are the most common cause of decompensation in multimorbid SNF patients 1

• Poor medication reconciliation: This leads to adverse drug events and readmissions 4, 2

• Insufficient RN staffing: Higher RN staffing reduces hospitalization rates, particularly for patients with longer SNF stays (>30 days) 1