Approximately 25% of Medicare patients hospitalized with heart failure are discharged to skilled nursing facilities and the numbers have tripled in the last 10 years. These patients have higher rehospitalization rates and mortality than those patients who are discharged to home. Skilled nursing facilities serve as a transitional site for debilitated heart failure patients where they regain function and independence following a hospitalization. Medicare allows up to 100 days of skilled nursing care post-hospitalization. Although the benefits of heart failure disease management programs targeted to the elderly have been established in other settings, there is little evidence of contemporary heart failure management integrated into the care delivered in the skilled nursing facilities. The proposed study is a 1:1 randomized cluster trial to study the effect of a heart failure disease management program for heart failure patients in skilled nursing facilities. The physicians who care for patients will serve as the cluster and each skilled nursing facility as the block. Each physician will be randomized to either manage their patients according to a heart failure disease management program or to usual care. The primary objective is to discern if a heart failure disease management program will decrease the composite outcome of all-cause hospitalizations, emergency department visits and mortality. The secondary objectives are to determine if a heart failure disease management program 1) improves patients'health status and heart failure self-care ability, 2) makes it more likely a patient will return home, rather tha be discharged to a facility and 3) is cost-effective. The primary hypothesis for this study is thata heart failure disease management program will decrease events in the composite outcome. The heart failure disease management program is based on best practices for heart failure and includes 7 elements of heart failure care: documentation of ejection fraction, symptom and activity assessment, daily weights/dietary surveillance, medication titration, patient and caregiver education, discharge instructions and a follow up visit within 7 days post-SNF discharge. A specialty trained heart failure nurse advocate will work closely with physicians. The heart failure nurse advocate will be responsible for all elements of the program to ensure fidelity of the intervention. Results from this study will determine if a heart failure disease management program in skilled nursing facilities improves patient outcomes and is cost-effective. These results will have the potential to have a large public health impact by transforming heart failure care for older adults who are cared for in skilled nursing facilities in the United States.

Public Health Relevance

The proposed research study is a trial of a heart failure disease management program compared to usual care in skilled nursing facilities for patients with heart failure. This proposal aims to determine if skilled nursing facilities adopt specific hert failure disease management practices will patients have fewer hospitalizations, emergency department visits and deaths. Since adults in skilled nursing facilities are debilitated and have many illnesses it is unknown if HF disease management will change their outcomes. If heart failure disease management is beneficial then there is potential for great public health impact for the aging population in the United States.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Study Section
Nursing and Related Clinical Sciences Study Section (NRCS)
Program Officer
Cooper, Lawton S
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Case Western Reserve University
Internal Medicine/Medicine
Schools of Medicine
United States
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Shah, Khanjan B; Rahim, Shiraz; Boxer, Rebecca S (2013) Heart failure readmissions. Curr Treat Options Cardiovasc Med 15:437-49
Boxer, Rebecca S; Dolansky, Mary A; Bodnar, Christine A et al. (2013) A randomized trial of heart failure disease management in skilled nursing facilities: design and rationale. J Am Med Dir Assoc 14:710.e5 -11