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

> **NIH NIH K23** · NEW YORK UNIVERSITY SCHOOL OF MEDICINE · 2020 · $181,456

## Abstract

PROJECT SUMMARY/ABSTRACT
 The primary objective of this application is to support Dr. Weerahandi's career development from a
mentored researcher to an independent clinician-investigator focused on improving patient outcomes by
targeting poor transitions and failures of care coordination. This K23 award will provide her with the support
needed to accomplish the following goals: (1) to develop skills in mixed methods research, (2) to conduct
investigations using large databases to identify systems level areas for intervention to improve transitions, (3) to
implement advanced biostatistical models in health services research, (4) to become an expert in health services
research on the post-acute management of heart failure (HF) patients. To achieve these goals, she has
assembled a multidisciplinary mentoring team. Dr. Horwitz, her primary mentor, is an accomplished clinician-
investigator focused on improving healthcare systems. Dr. Jones, her co-mentor, is a statistician who will
supervise Dr. Weerahandi's training in advanced survival analyses methods. Her scientific advisors include Dr.
Boxer, an experienced health services researcher in the area of HF management in skilled nursing facilities
(SNF) and Dr. Dodson, a geriatric cardiologist who will oversee Dr. Weerahandi's training in geriatric HF
management.
 Discharge to SNF is common in HF patients, occurring in 1 in 5 Medicare beneficiaries after HF
admission. Despite the prevalence of discharge to SNF, little is known about the transition from SNF to home.
While studies have examined the transition from hospital to home, the quality of the specific transition from SNF
to home for patients with HF is unknown. Ideally, transitional care should occur when patients are discharged
from SNF to home. Yet it is uncertain to what degree and with what quality such practices are performed. The
research objective of this application is to better characterize discharge process quality during the transition from
SNF to home after a HF hospitalization. Dr. Weerahandi will conduct a convergent mixed-methods study to
assess discharge process quality from SNF to home by interviewing staff, patients, and caregivers; and
examining discharge instructions elements (Aim 1). While Dr. Weerahandi's long term goal is to create effective
systems level interventions to improve this transition, patient level factors that may drive readmission and
mortality in Medicare populations must also be accounted for, particularly degree of frailty and cognitive
impairment. Informed by her preliminary data, she will conduct a retrospective cohort study using Medicare data
linked with the Minimum Dataset to determine if frailty score or degree of cognitive impairment are associated
with adverse events following the transition from SNF to home after HF hospitalization (Aim 2). This research
plan takes advantage of existing resources including Dr. Horwitz's AHRQ- funded research group, Dr. Boxer's
NHLBI-funded research group and the NY...

## Key facts

- **NIH application ID:** 9980993
- **Project number:** 5K23HL145110-02
- **Recipient organization:** NEW YORK UNIVERSITY SCHOOL OF MEDICINE
- **Principal Investigator:** Himali Weerahandi
- **Activity code:** K23 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $181,456
- **Award type:** 5
- **Project period:** 2019-08-01 → 2024-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9980993

## Citation

> US National Institutes of Health, RePORTER application 9980993, Characteristics of Transitions from Skilled Nursing Facility to Home Following Heart Failure Hospitalization (5K23HL145110-02). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9980993. Licensed CC0.

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