What is the management approach for congestive heart failure (CHF) in a Skilled Nursing Facility (SNF) setting?

Management of Congestive Heart Failure in Skilled Nursing Facilities

Continue guideline-directed medical therapy (ACE inhibitors/ARBs, evidence-based beta-blockers, and mineralocorticoid receptor antagonists) along with volume management until limited by decreased oral intake, inability to swallow, or hypotension, while implementing intensive surveillance for infections, electrolyte imbalances, and early signs of decompensation. 1

Medication Management

Core Pharmacotherapy for HFrEF

For patients with heart failure with reduced ejection fraction (LVEF ≤35-45%), maintain the following evidence-based medications: 1

• ACE inhibitors or ARBs - Continue unless contraindicated by hypotension, hyperkalemia (K+ >5.5 mEq/L), or significant renal dysfunction 1
• Evidence-based beta-blockers ONLY - Use carvedilol, metoprolol succinate extended-release, or bisoprolol; convert patients on other beta-blockers to one of these three 1
• Mineralocorticoid receptor antagonists - Use low-dose spironolactone (≤25 mg/day) or eplerenone only if symptomatic despite ACE inhibitor/ARB and beta-blocker, with careful potassium monitoring 1
• Digoxin - Use low-dose only (≤0.125 mg/day) if symptomatic despite optimal therapy 1

Volume Management

Daily weight monitoring is mandatory with specific intervention thresholds: 1

• Weight gain of 3-5 lbs over 3-5 days requires licensed nursing staff to perform advanced assessment including jugular venous pressure, peripheral edema assessment, lung auscultation for crackles, and oxygen saturation 1
• Increase oral or intravenous diuretics for documented volume overload with stable vital signs 1
• Continue diuretic therapy throughout the disease course, including end-of-life care, until limited by inability to take oral medications or hypotension 1

Surveillance and Early Detection

Priority Monitoring Parameters

Implement daily assessment protocols focusing on the most common causes of rehospitalization: 1

• Infections - Monitor for respiratory tract infections, urinary tract infections, and sepsis with daily vital signs and mental status checks 1
• Electrolyte imbalances - Check comprehensive metabolic panel when clinical status changes, particularly monitoring potassium in patients on RAAS inhibitors 1
• Mental status changes - Document cognitive function daily as altered mental status is a common rehospitalization trigger 1
• Volume status - Assess for progressive symptoms over 7 days before overt decompensation: increasing fatigue, dyspnea on exertion, cough, edema, and weight gain 1

Physical Assessment Technique

For jugular venous pressure assessment (critical volume status indicator): 1

• Position patient between supine to sitting to visualize the top of venous pulsation 1
• Use either internal or external jugular vein 1
• Add the distance in centimeters for jugular pulsations above the sternal angle; subtract for pulsations below 1

Goals of Care and Treatment Intensity

Stratify Patients by Clinical Scenario

Rehabilitation patients with anticipated discharge home receive full guideline-based care with aggressive management of decompensation, including hospitalization if oral diuresis fails in the SNF. 1

For patients with uncertain goals or limited life expectancy (particularly those with moderate-to-severe dementia and HF decompensation who may have <1 year life expectancy), initiate advance care planning discussions at SNF admission and with any change in health status. 1

Palliative Care Integration

Symptom management is mandatory throughout the disease course, not just at end-of-life: 1

• Assess dyspnea by patient self-report (observation alone is inadequate due to ergoreflex activation causing tachypnea) 1
• Use opioids for dyspnea management in advanced HF (safe and effective in small studies) 1
• Assess and treat pain, anxiety, depressive symptoms (paroxetine is effective), and fatigue regularly 1
• Continue HFrEF medications and volume management at end-of-life until limited by decreased oral intake, inability to swallow, or hypotension 1

Device Management

For patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy (CRT): 1

• Include device deactivation preferences in advance care planning discussions at SNF admission 1
• Ensure patient preferences are informed through prior consultation with a cardiologist who can educate about the device 1
• Follow formal deactivation protocol requiring written physician order, documentation of patient/surrogate capacity, and confirmation of alternative therapy discussions 1

Education and Disease Management

Intensive educational and behavioral interventions for patients and/or caregivers must accompany guideline implementation. 1

Key educational components for SNF staff include: 2

• Identification of HF patients and recognition of HF signs/symptoms 2
• Purpose and technique of daily weights 2
• Indicators of worsening HF requiring intervention 2
• Rationale for sodium-restricted diet 2
• Materials to improve patients' understanding of their HF 2

Quality Improvement Strategies

Implement the following system-level interventions to improve HF care: 1

• Chart audit and feedback of results 1
• Reminders to consider specific medications or tests 1
• Clinical decision support tools 1
• Collaboration with local HF experts or community/hospital-based HF specialists 1

Common Pitfalls to Avoid

• Do not use non-evidence-based beta-blockers - Only carvedilol, metoprolol succinate ER, and bisoprolol have mortality benefit data 1
• Recognize cognitive impairment limits symptom reporting - Sedentary lifestyles and comorbid illnesses create overlapping symptom profiles; absence of symptoms at rest does not indicate stable HF 1
• Avoid delaying intervention for weight gain - Progressive symptoms occur over 7 days before overt decompensation 1
• Do not assume all HF patients require hospitalization for decompensation - Patients with stable vital signs can receive oral or IV diuresis in the SNF 1
• Medicare regulations prohibit simultaneous SNF Medicare benefit and hospice benefit - Patient must be in non-Medicare-reimbursed bed (private pay) to receive hospice in SNF 1

Outcomes to Monitor

Evaluate the following outcomes for quality improvement: 1

• Reduced hospitalization or readmission rates 1
• Fewer HF symptoms and improved activity level 1
• Improved self-management 1
• Maintenance or improvement of independence and quality of life 1
• Survival 1

Note: A 2022 randomized controlled trial demonstrated that structured HF disease management programs in SNFs significantly reduced 60-day hospitalization rates (43% vs 54%, P=0.04) and mortality (5.2% vs 10.8%, P<0.001) compared to usual care, with particular benefit for patients with primary HF discharge diagnoses. 3, 4