Heart Failure Disease Management Program in Skilled Nursing Facilities for Reduced Rehospitalizations and Mortality

Heart failure patients who are discharged to skilled nursing facilities face higher risks of rehospitalization and mortality compared to those who return home. Currently, there are no national guidelines for heart failure disease management programs in skilled nursing facilities, despite evidence that such programs can reduce rehospitalizations in community settings. This study aims to evaluate the impact of a heart failure disease management program on patients' outcomes within 30 days post-admission to a skilled nursing facility, with a focus on preventing rehospitalizations, emergency room visits, and mortality. Patients participating in this study will be cared for either through a specialized heart failure disease management program or usual care. The program consists of seven components designed to manage heart failure effectively. The study's primary outcome is to measure the difference in the composite endpoint of 60-day all-cause hospitalization, all-cause emergency department visits, and all-cause mortality between patients in skilled nursing facilities who receive care via the disease management program versus usual care.