Patients Denied Home Health After SNF Experience 32% Higher Mortality

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A study published in the Journal of the American Geriatrics Society in January reports that heart failure patients discharged from a skilled nursing facility (SNF) without home health have 32% higher mortality compared to patients who receive home health.1SNF discharges denied home health also experience 11% more rehospitalizations within 30 days, and those rehospitalizations occur earlier. Unfortunately, the study also shows that eight out of ten Medicare beneficiaries discharged from an SNF with heart failure do not receive home health. The data lends encouragement to doctors and careplanners who are ordering home health following SNF stays.

Himali Weeahandi, MD, of the NYU School of Medicine, and her research colleagues, reviewed all Medicare fee-for-service records for patients age 65+ who were discharged from a hospital to an SNF for heart failure. There were 67,585 discharges between 2012 and 2015. The current study adds to the results of a 2017 study reporting that across all diagnoses, prompt home health following SNF discharge decreases the risk of 30-day rehospitalization by 39%.

There’s a likelihood that home health utilization among seniors with heart failure is already better than the 20% found in the 2012 to 2015 data. As of 2018, Medicare has been using value-based purchasing with SNFs. Skilled nursing facilities with a 30-day rehospitalization rate in the bottom 40% get a 2% payment penalty from Medicare. Referring all homebound patients to home health stands out as an easy strategy for lowering rehospitalization ratesand improving patient survival.

Nearly all Medicare beneficiaries returning home from an inpatient stay have a skilled need for medication reconciliation. There may also be a need for observation & assessment, follow-up rehab, diet teaching, ensuring adherence with the plan of care, and other services. Therefore, when discharged patients are also homebound, protecting patients with home health is an easy decision.

Same-Day Response Available

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Many of your referrals should notwait days for home health to begin. Home infusion nursing, postsurgical rehab, transitionalcare management, and other cases need prompt response to achievethe best possible outcomes. This iswhy My Home Nurses makes same-day response available for your most pressing casesand works to ensure the timeliestresponse possible for all other referrals. When your patients need prompt, personal attention, please call My Home Nurses.

Please tell your patients about My Home Nurses.


  1. WeerahandiH, Bao H, Herrin J, Dharmarajan K, Ross JS, Jones S, Horwitz LI. Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization. Journal of the American Geriatrics Society. 2020 Jan; 68 (1): 96-102.
  2. Carnahan JL, Slaven JE, Callahan CM, Tu W, Torke AM. Transitions from skilled nursing facility to home: The relationship of early outpatient care to hospital readmission. Journal of the American Medical Directors Association. 2017 Oct 1;18(10):853-9.
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