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J Am Geriatr Soc. 2020 Jan;68(1):96-102. doi: 10.1111/jgs.16179. Epub 2019 Oct 11.

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization.

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Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, New York, New York.
Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, New York.
Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, New York.
Center for Outcomes Research and Evaluation, Yale University, New Haven, Connecticut.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Clover Health, Jersey City, New Jersey.
Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.



Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization.


Retrospective cohort study.


Fee-for-service Medicare data, 2012 to 2015.


Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home.


The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model.


Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P < .0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86-0.95) with receipt of HHC.


Recipients of HHC were less likely to be readmitted within 30 days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services. J Am Geriatr Soc 68:96-102, 2019.


heart failure; home healthcare; readmission; rehabilitation; skilled nursing facility; transitions

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