Ideal Follow-Up Plan of Care After Discharge from Skilled Nursing Facility

Key Components of Post-SNF Discharge Care

The American Heart Association recommends scheduling a follow-up appointment with the patient's primary provider within 7 days of SNF discharge to ensure continuity of care and prevent gaps in treatment 1
For stroke patients, the American Stroke Association recommends arranging formal assessment of mobility, activities of daily living (ADL), and communication/cognition by appropriate clinicians within 30 days of discharge 2
The American College of Cardiology recommends scheduling follow-up with the heart failure specialist within 7 days as this provides an important link back to community care 1

The American Heart Association recommends ensuring bidirectional verbal and written communication between the SNF and receiving providers that includes essential clinical data, important decisions/events during the SNF stay, medication list, plan of care, and patient/family education 1, 3

The American Stroke Association recommends developing a tailored exercise and fitness program for patients returning home to enhance cardiorespiratory fitness and reduce risk of readmission 2
The American Heart Association recommends assessing self-management capabilities and making appropriate referrals for home health care if needed 1

The American Stroke Association recommends arranging formal assessment of ADL and instrumental ADL (IADL) status directly related to the discharge living setting 2
The American Stroke Association recommends scheduling follow-up on communication abilities and functional mobility within 30 days 2
The American Stroke Association recommends providing ongoing support for caregivers, which has been shown to favorably affect both stroke survivor and caregiver outcomes 2, 4

The American College of Cardiology recommends monitoring for signs of congestion, electrolyte imbalances, infections, and altered mental status as these are common reasons for rehospitalization 5, 6
The American College of Cardiology recommends scheduling a 7-day follow-up appointment with the heart failure provider 1
The American College of Cardiology recommends establishing target weight, heart rate, and blood pressure goals 3

The American Stroke Association recommends assessing caregiver needs and concerns from their perspective 4, 7
The American Stroke Association recommends providing caregivers with information about support groups, home help options, and rehabilitation resources 4
The American Stroke Association recommends maintaining contact with family caregivers after discharge (at 1, 4, 6, and 12 months) 7

The American College of Cardiology recommends implementing careful surveillance for infections, electrolyte imbalances, and mental status disturbances, which are common causes of readmission 5, 6
The American Heart Association recommends ensuring proper medication reconciliation to prevent adverse drug events 3
The American Stroke Association recommends providing clear instructions on warning signs that require medical attention 7
The American Heart Association recommends considering using quality improvement tools like INTERACT (Interventions to Reduce Acute Care Transfers) to manage acute changes in patient conditions 1

The American Heart Association recommends avoiding inadequate communication between facilities, which can lead to adverse events, increased costs, and increased length of stay 1
The American Heart Association recommends avoiding lack of follow-up appointments within 7 days, which may result in care gaps and potential readmissions 1
The American Stroke Association recommends avoiding insufficient caregiver education and support, which can lead to poor outcomes and increased caregiver strain 4, 7
The American Stroke Association recommends avoiding failure to assess functional status within 30 days, which may miss opportunities for intervention 2