# Characteristics of Transitions from Skilled Nursing Facility to Home Following Heart Failure Hospitalization

> **NIH NIH K23** · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · 2023 · $54,000

## Abstract

Project Summary/Abstract
 Many older patients are discharged to a skilled nursing facility (SNF) after hospitalization to improve
function before returning home; consequently, they may incur a second transition, from SNF to home, within 30
days of hospital discharge. Despite the prevalence of discharge to SNF, little is known about the transition from
SNF to home. We previously demonstrated that almost a quarter of patients discharged from SNF to home
after heart failure hospitalization were readmitted within 30 days of SNF discharge. This high proportion of
readmissions among temporary SNF patients suggests further work is needed to examine the transition from
SNF to home and to identify drivers of rehospitalization after SNF discharge.
 Dr. Weerahandi’s long term goal is to create effective systems level interventions to improve transitions
of care. Cognitive impairment and frailty resulting from disease states such as Alzheimer’s disease and related
dementias (AD/ADRD) are a risk factors for adverse events in the hospital to home transition, and likely also
affects the transition from SNF to home. Ideally, these factors should be addressed upon discharge from SNF
to ensure a safe transition home. Yet it is uncertain to what degree and with what quality such practices are
performed and if they are tailored to the needs of those with AD/ADRD.
 The objectives of this administrative supplement are to (1) build on the research infrastructure from Dr.
Weerahandi’s career development award to study the transition from SNF to home after hospitalization in
patients with AD/ADRD and (2) to expand Dr. Weerahandi’s research program to focus on outcomes for
patients that are at particularly high risk of adverse outcomes during care transitions: patients with AD/ADRD.
Funding from this supplement will be used to analyze Medicare data to determine the risk of readmission from
SNF to home for patients with AD/ADRD and evaluate the quality and experience of the SNF discharge
process for these patients.

## Key facts

- **NIH application ID:** 10711710
- **Project number:** 3K23HL145110-05S1
- **Recipient organization:** UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
- **Principal Investigator:** Himali Weerahandi
- **Activity code:** K23 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2023
- **Award amount:** $54,000
- **Award type:** 3
- **Project period:** 2022-07-01 → 2024-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10711710

## Citation

> US National Institutes of Health, RePORTER application 10711710, Characteristics of Transitions from Skilled Nursing Facility to Home Following Heart Failure Hospitalization (3K23HL145110-05S1). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10711710. Licensed CC0.

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