Abstract
OBJECTIVE: We report on a skilled nursing facility (SNF) that added designated heart failure (HF) beds and created a patient registry to track the number and reasons for rehospitalization. BACKGROUND: Targeting the reduction of rehospitalizations from SNFs is an important goal and patients with HF are particularly vulnerable for rehospitalizations as HF disease management programs in SNFs are rare. METHODS: A case study of a local quality improvement initiative. RESULTS: The data from the registry revealed, that compared to patients without HF, patients with HF were more often rehospitalized for cardiopulmonary symptoms and less often for infection. In addition, patients with HF were most often rehospitalized during the first 7 days of their SNF stay and if they had a primary hospital discharge diagnosis of HF. CONCLUSION: We highlight the benefits of a patient registry to guide future quality improvement initiatives to reduce patient rehospitalization rates.