Targeting heart failure rehospitalizations in a skilled nursing facility: A case report.

The results came from only one institution, and the paper states they cannot be generalized. The main rehospitalization drop from 43% to 30% was reported with p=0.07. The facility changed several things at once, including specialty HF beds, coaching, staff training, patient education, dietician support, discharge planning, and a registry, so the paper cannot separate the effect of any single component. The registry was created manually and required staff time to read nursing notes, making data capture time consuming and potentially inaccurate. There was no standardization of documentation for reason for hospitalization, and SNF staff did not have a medical diagnosis at the time of transfer. The project was funded by an outside source.

The facility received grant funding to increase efforts to reduce rehospitalizations, and the paper states the project was funded by an outside source. No other conflicts of interest are reported in the supplied text.

Do not conclude that any single HF care change caused the drop in rehospitalizations. The facility added specialty HF beds, a nurse practitioner coach, a physician facilitator, staff training, patient education modules, dietician support, structured discharge planning, and a registry, and the paper does not separate their effects. The change from 43% to 30% had p=0.07, and the paper states the results came from only one institution and cannot be generalized.