What questions should I ask a patient with a history of chronic conditions, recently discharged home after receiving rehabilitation at a Skilled Nursing Facility (SNF), during a follow-up call to assess their recovery and potential complications?

Post-SNF Discharge Follow-Up Call: Essential Questions

Your follow-up call should systematically assess functional recovery, medication adherence, symptom progression, and care coordination to prevent avoidable rehospitalization, which occurs in approximately 30% of SNF discharges within 30 days. 1, 2

Functional Status and Activities of Daily Living

Ask specifically about their ability to perform bathing, dressing, toileting, transferring, continence, and feeding — only 30% of patients with new ADL disabilities during hospitalization return to their prior level of functioning. 1

• "Can you bathe, dress, and use the toilet independently, or do you need help?" — Gross motor coordination and manual dexterity are associated with successful transition without disability. 1
• "Are you able to walk around your home safely? Where do you walk?" — Deconditioning increases fall and fracture risk. 1
• "Have you had any falls or near-falls since going home?" — This identifies immediate safety concerns requiring intervention. 1

Symptom Assessment and Warning Signs

Directly ask about progressive symptoms that signal decompensation: increasing fatigue, dyspnea on exertion, cough, edema, and weight gain. 3

• "Are you more short of breath today compared to yesterday, especially with activity?" — Symptom burden comparison with the prior day helps avert hospitalization. 1
• "Can you lie flat in bed, or do you need extra pillows to breathe comfortably?" — Orthopnea indicates volume overload. 1
• "Have you noticed swelling in your legs, ankles, or abdomen?" — Increasing edema signals worsening heart failure or fluid retention. 1, 3
• "Have you weighed yourself daily? What has your weight been doing?" — A gain of 3-5 lbs over 3-5 days requires immediate assessment. 1, 3

Medication Management

Verify they understand their medications, have adequate supply, and are taking them correctly — medication nonadherence and reconciliation errors are common causes of HF exacerbations. 1

• "Do you have all your medications at home? When do you run out?" — Identifies gaps in medication supply before they become critical. 1
• "Can you tell me what your water pill (diuretic) does and when you take it?" — Assesses understanding of critical HF medications. 1
• "Are you taking any over-the-counter pain medications like ibuprofen or naproxen?" — NSAIDs worsen heart failure and renal function. 1, 3
• "Have you been using any salt substitutes?" — Potassium-based salt substitutes increase hyperkalemia risk, especially with ACE inhibitors/ARBs. 1, 3

Dietary and Fluid Management

Ask about sodium intake and fluid consumption — dietary sodium excess is a common precipitant of HF exacerbations. 1

• "Are you following a low-salt diet? What did you eat yesterday?" — Identifies high-sodium food consumption. 1
• "Are family members bringing in outside food?" — Family-provided foods are often high in sodium. 1

Infection and Associated Medical Conditions

Screen for infections, which are among the most common triggers for decompensation — pneumonia, sepsis, and urinary tract infections frequently precipitate HF exacerbations. 1

• "Do you have any fever, chills, or feel like you're getting sick?" 1
• "Do you have a cough? What color is the sputum?" — Identifies possible pneumonia. 1
• "Any burning with urination or urinary frequency?" — Screens for UTI. 1

Follow-Up Appointments and Care Coordination

Confirm they have scheduled and can attend their 7-day follow-up appointment — early outpatient follow-up is critical to prevent rehospitalization. 1

• "When is your next doctor's appointment? Do you have a way to get there?" 1
• "Which doctor is managing your heart failure?" — Ensures appropriate specialist follow-up. 1
• "Do you have home health services set up? When do they visit?" — Verifies care coordination is in place. 1

Psychosocial Support and Caregiver Assessment

Evaluate whether they have adequate support at home — physical and cognitive dysfunction, sensory impairments, and lack of psychosocial support compromise self-care capacity. 1

• "Who is helping you at home? Are they available when you need them?" 1
• "Do you feel safe at home?" — Identifies potential abuse or neglect situations. 1

Red Flag Assessment Requiring Immediate Action

If the patient reports any of the following, arrange urgent evaluation or direct them to call 911: 1

• Severe shortness of breath at rest
• Chest pain or pressure
• Confusion or altered mental status
• Inability to perform basic self-care
• Symptomatic hypotension or dizziness with standing
• Weight gain >5 lbs in 3-5 days with dyspnea

Common Pitfalls to Avoid

• Don't delay assessment if symptoms are present — 30% of adverse events occur within the first 5 days post-discharge. 2
• Don't assume written discharge instructions were understood — health literacy varies widely, and verbal reinforcement is essential. 1
• Don't overlook medication reconciliation errors — these are provider/system factors contributing to HF exacerbations. 1