title: A randomized trial of heart failure disease management in skilled nursing facilities: design and rationale.
abstract: BACKGROUND
  Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults.
  The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days post-SNF admission. The trial is a randomized cluster trial to be conducted in 12 for-profit SNF in the greater Cleveland area. The study population is inclusive of patients with HF regardless of ejection fraction but excludes those patients on dialysis and with a life expectancy of 6 months or less. The HF-DMP includes 7 elements considered standard of care for patients with HF documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7-day follow-up appointment post-SNF discharge, and patient education. The HF-DMP is conducted by a research nurse tasked with adhering to each element of the program and regularly audited to maintain fidelity of the program. Additional outcomes include health status, self-care management, and discharge destination.
  
  
  CONCLUSIONS
  The SNF-Connect Trial is the first trial of its kind to assess if a HF-DMP will improve outcomes for patients in SNFs. This trial will provide evidence on the effectiveness of HF-DMP to improve outcomes for older frail HF patients undergoing postacute rehabilitation.
authors.affiliation: Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH. Electronic address: rebecca.boxer@case.edu.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Boxer
authors.forename: Mary A
authors.initials: MA
authors.lastname: Dolansky
authors.forename: Christine A
authors.initials: CA
authors.lastname: Bodnar
authors.forename: Mendel E
authors.initials: ME
authors.lastname: Singer
authors.forename: Jeffery M
authors.initials: JM
authors.lastname: Albert
authors.forename: Stefan
authors.initials: S
authors.lastname: Gravenstein
mesh_terms: D000368:Aged; D019468:Disease Management; D005260:Female; D006305:Health Status Indicators; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D009820:Ohio; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D012648:Self Care; D012866:Skilled Nursing Facilities; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
keywords: Heart failure; SNF; disease management