Management of Heart Failure in Skilled Nursing Facilities: Why Does it Matter?

Approximately one-fourth of older adults hospitalized with heart failure (HF) are discharged to skilled nursing facilities (SNFs) rather than sent home.^1,2 Compared with HF patients who were discharged to home, patients discharged to SNFs had a 76% increased risk of death one year post discharge and approximately 25% are likely to be rehospitalized within 30 days of hospital discharge. The HF patients in SNFs are generally older (greater than 80 years of age), have multiple comorbidities such as strokes and cognitive impairment and are frailer than those who are discharged from hospitals to home settings.²

HF Care Guidelines for SNFs

No care guidelines for HF have been established for patients in SNFs.³ Guidelines established for the overall management of HF^4,5 are applied to those in SNFs and providers are held accountable to these guidelines. The most recent American College of Cardiology Foundation/American Heart Association guidelines for example comprehensively address the definition and diagnosis of HF, appropriate evaluation (including family and genetic screening/counseling) and management recommendations. Management includes medication management (guideline directed medical therapy), use of cardiac resynchronization therapy and advanced HF management involving ventricular assist technologies.⁵ The guidelines do not specifically take into consideration the types of patients or providers commonly found in SNFs. For example, there is no clear guidance for those with multimorbidities or for those with cognitive impairment.

Opportunities and Challenges to Management of HF in SNFs

There are many potential advantages to managing HF for older adults in SNFs. These settings, which provide 24 hour nursing care and include involvement of multiple members of the health care team (pharmacy, social work, physical, occupation and speech therapy, activities, nutrition among others), can help assure that medications and diets are adhered to as recommended in guidelines. Moreover, the multiple care providers in these settings can further help assure that commonly recommended “self-care” behaviors such as measuring weight daily and exercise are implemented. There are, however, numerous challenge management of HF in SNFs.

Challenges in these settings include the knowledge base of the providers about optimal management of HF, the philosophy of care in these settings, and the type of patients likely to need and receive SNF level care following an acute care admission for HF. With regard to knowledge base of providers, direct care workers and licensed practical nurses provide the majority of the direct patient nursing care including personal care activities such as bathing and dressing, monitoring of vital signs and administering medications or overseeing the administration of medications by medication technicians.

The majority of nurses in SNFs are older and are licensed practical nurses and as such may not be familiar with the types of drugs being prescribed for HF or the rational for their use. It is not unusual in these settings for the nurse to “hold” a beta blocker in an asymptomatic resident because the resident’s blood pressure was low. The assumption is that the medication is for hypertension rather than management of HF. Thus there is a clear need for education about physiology of HF and current management recommendations.^{1-3 6} Nursing education in HF is needed to help with identification of patients/residents with HF, recognition of the signs and symptoms of HF, identification of and communication to other members of the health care team about clinical measures of HF and important self-management of HF for older adults to adhere to when they are discharged home from the SNF.

Another challenge to management of HF in SNFs is that the care recommendations for optimal management of patients with HF and the goals or philosophy of care in SNFs are not consistent. One of the goals of HF management is to reduce mortality by altering the natural history of the disease ⁵; typically, this means delaying its progression. Conversely, a major focus of care in SNFs today includes a person- centered care approach.⁷ Person-centered care is an approach that encourages choice, purpose and meaning in daily life. It is focused on helping individuals achieve the level of physical, mental and psychosocial well-being that is optimal for them. A patient-centered care approach may not help to reduce mortality. For example, an individual may feel that his or her quality of life is impaired if high sodium foods are restricted and thus may refuse a low sodium diet. Likewise, this individual may not want to take certain medications due to side effects, may refuse to exercise, or may refuse to have his or her weight obtained on a daily basis. Refusal of recommended medical interventions as per guidelines is highly supported in SNFs. These personal care decisions are generally supported and accepted regardless of the individual’s cognitive status and understanding of the risk of his or her decision. In addition, given the focus on quality of life rather than disease management, there is little incentive among staff to aggressively weigh residents daily, to limit or moderate fluid intake or to encourage the resident to engage in any other potentially unpleasant management approaches recommended for HF.

Patients/Residents in SNFs

Patients from acute care settings most likely to be discharged to SNFs are likely to be more clinically challenging than those who are discharged home. These patients include those who are older, have comorbidities, have poorer mobility, greater cognitive impairment, are frailer and those that lack a caregiver.^{1,2 8,9, 10} It should be recognized that these types of patients are also the ones who were underrepresented in clinical trials used to develop guidelines of HF care. In addition, these individuals are at greater risk of adverse effects associated with the recommended medical management of HF. Specifically, they are more sensitive to the hypotensive effects of all vasodilators and to age-related renal insufficiency associated with treatment. Cognitive impairment and urinary incontinence, common among these residents, makes it particularly challenging to obtain accurate intake and output. Further, residents in these settings may go to activities during the day and eat meals in a community dining room further complicating the nurses’ ability to monitor fluid and food intake and the types of snacks provided.

End-of-Life Focus

In light of the frailty and compromised health status of the patients discharged to SNFs, end-of-life decisions and services often becomes a more critical aspect of care than aggressive adherence to HF guidelines. It is particularly important to address and consider end-of-life care in residents who have advanced, persistent HF with symptoms at rest despite the use of guideline driven and evidence based interventions^11. Discussions with residents with advanced HF and their families should address treatment preferences and provide guidance for how the staff should proceed if the individual experiences an acute event such as cardiac arrest or stroke, whether or not to inactivate an implantable cardioverter-defibrillator, and whether or not to continue pharmacologic therapies for the treatment of HF (e.g., ACEIs, β-blockers, ARAs, hydralazine/ISDN, diuretics, digoxin). Treatment at this time is focused on the immediate clinical benefits of interventions and how they impact quality of life versus potential side effects such as refractory hypotension or difficulty actually taking/swallowing the medication, urinary urgency or constipation. Symptoms associated with HF such as dyspnea can be managed palliatively with opioids or diuretics.

Next Steps

Where do we need to go at this point with HF management in SNFs? Research is needed to better understand the utility of interventions for older adults in terms of quality of life, particularly for those 90 years of age and above.^11,12 For example, behavioral interventions such as exercise and diet need to be tested as do newer approaches such as use of devices. These findings can help establish appropriate guidelines for older adults in SNFs to assure affordable, high quality care.