Medical care in skilled nursing facilities (SNFs) in the United States

INTRODUCTION — 

Skilled nursing facility (SNF) care in the United States includes both long-term residential care and short-term postacute or rehabilitative care following a hospitalization. There are various terms used to describe nursing facilities, including nursing home, nursing facility, and long-term care facility. In this chapter, we will use the term SNF in lieu of other terminology, recognizing that not all, but the vast majority (95 percent) of facilities have beds that are certified by Medicare as "skilled." SNFs are an important site for medical care; there are over 15,000 SNFs in the United States [1]. People are eligible to receive care in SNFs if they have significant care needs, including medical complexity, need for assistance with activities of daily living (ADL), and/or rehabilitative care.

Clinical care in the SNF setting is challenging because of the heterogeneity of the population and their vulnerability to adverse outcomes. In addition, delivering clinical care may be challenging due to system issues such as chronic nursing or nurse aide staffing shortages. For certain conditions, medical management is similar to outpatient management. In this chapter, we will focus on those conditions in SNF patients that warrant a particular approach or heightened awareness. Many are geriatric syndromes that comprise constellations of symptoms that may have any of several etiologies. The topic will also address regulatory and epidemiologic issues that bear on clinician practice.

Specific issues in this population are also discussed separately. (See "Outbreaks in long-term care facilities: Detection and management" and "Palliative care: Nursing home" and "Principles of infection prevention and control in long-term care facilities".)

THE SNF POPULATION — 

The SNF population includes patients who are admitted for postacute care under a Medicare benefit for short-stay rehabilitation and nursing and medical services (referred to as "patients" in this chapter) and a long-stay population (referred to as "residents," defined by the Centers for Medicare and Medicaid Services [CMS] as 100 or more days) who are receiving supportive services and medical care [2]. The majority of initial admissions to a SNF come from an acute-care or acute-rehabilitation hospital and typically require rehabilitation, in addition to regular nursing and medical services, with the goal of safely returning to living at a lower level of care in the community (algorithm 1). The model SNF has a capacity of 100 patients, with 15 to 20 percent of patients admitted for postacute care and considered "short stay" and the remainder being more stable, long-stay residents; however, there is substantial variability. Once short-stay patients reach their rehabilitation goals and are medically stable, they are either discharged to a lower level of care (eg, to home or an assisted living facility) or transitioned to a long-stay resident if a lower level of care is not safe or feasible [2].

SNF patients and residents are generally older adults (>90 percent older than age 65; close to 40 percent age 85 and older), female (approximately 70 percent), and have multiple impairments in their activities of daily living (ADL). Cognitive impairment is also common, with 37 percent exhibiting severe impairment and 25 percent having moderate impairment [1]. Individuals under the age of 65 years old who receive care in SNFs usually have different comorbidities and needs (eg, head injury, serious mental illness, and substance use disorders).

FINANCING OF SNF CARE — 

Medicare pays for limited, postacute care days in SNFs; Medicaid pays for a majority of SNF days in the United States. Clinicians should be aware of how SNF care is financed since it can affect decisions about location and level of care. SNF care represents a substantial segment of health care costs for older adult individuals [3]. Expenditures for SNF care rose to just over USD $172 billion in 2019 [4], and with the growth of postacute SNF care, the Medicare share of these costs has risen to close to 20 percent.

Many Americans, including health care professionals, do not understand how care in SNFs is financed. Close to 75 percent of Americans believe that if they need care in a SNF, Medicare will pay for it. However, because Medicare does not pay for assistance with activities of daily living (ADL; "custodial" or supportive care), funding for long-term residents is private pay or through Medicaid for individuals who meet the financial means test for this program in their state of residence. This can result in a phenomenon termed "spend down," in which individuals and their families are responsible for paying for long-term care in a SNF until they become impoverished enough to qualify for Medicaid. The average monthly costs of long-term care in a SNF are now in the range of USD $7500 to $9000, depending on whether the room is single or double occupancy, and can be much higher in some SNFs [5].

The costs of care are covered differently, depending on whether the patient/resident is receiving long- or short-term care:

●Room and board costs for long-term residents (considered by Medicare as those residents whose stay extends beyond 90 days) are generally paid for by Medicaid, for those who meet the means test in their state of residence, or are paid out-of-pocket by residents or their families. Long-term care insurance policies may cover a portion of the daily rate, but these policies can be expensive and have limited benefits.

●For short-term patients discharged from a hospital setting, Medicare will pay for those with the need for rehabilitation to regain function due to deconditioning or who have medical instability requiring frequent nursing and/or medical intervention.

●In the Medicare fee-for-service (FFS) system, a patient must be in an acute hospital as an inpatient for 72 hours (three midnights) to activate the Medicare SNF benefit. Although the benefit period can last for 100 days, a substantial copay is required after day 21. The average length of stay in a Medicare-covered SNF postacute episode is approximately 25 days and is declining because of value-based/managed care reimbursement strategies. A Medicare supplement policy may cover the cost of copays for SNF stays.

•For Medicare beneficiaries enrolled in Medicare Advantage plans (eg, Medicare managed care, institutional special needs plans, and bundled payments), the plan determines where and for how long the stay will be covered. Some Medicare Advantage plans can obtain a waiver of the 72-hour rule and directly admit patients to the SNF. The length of stay for these patients is generally shorter because of the financial incentives for care at the lowest level that is safe and feasible and the availability of more case management services.

●Because Medicare Part A finances both short-stay postacute SNF care and hospice care, it will not cover both services at the same time. Thus, if a patient on the postacute SNF benefit elects to go on hospice, they are financially responsible for the room and board costs of the stay (if they do not have Medicaid coverage), which can be substantial. (See 'Hospice and palliative care' below.)

QUALITY OF CARE IN THE SNF — 

Many SNFs provide excellent quality of care; however, quality is inconsistent across SNFs. Staffing shortages and the financial impact of lower occupancy following the coronavirus disease-2019 (COVID-19) pandemic impacted the ability of SNFs to provide high-quality care. A commonly used reference for SNF quality is the publicly reported Centers for Medicare and Medicaid Services (CMS) Care Compare rating system. SNF quality of care is rated by CMS on a five-star system that has three core components. The most heavily weighted is state inspection scores; staffing levels and performance on several quality measures are also considered. Approximately 10 percent of SNFs are rated as five stars; 70 percent as four, three, or two stars; and 20 percent as one star. While the validity of these ratings is questioned by many in the industry, they remain the measure that the public sees on the CMS website and are used by researchers as well as by health systems and health plans to make decisions about SNF partnerships. In the setting of ongoing concerns about quality of care in SNFs and the devastating impact of the COVID-19 pandemic, the National Academies of Sciences, Engineering, and Medicine has released a report articulating seven goals for improving SNF care [6].

The Minimum Data Set — In response to concerns about the quality of SNF care, the Omnibus Reconciliation Act of 1987 (OBRA-87) mandated that all SNFs complete a comprehensive evaluation of residents within 14 days of the time of admission, an assessment that is intended to serve as the basis for the plan of care while in the SNF. A pivotal part of the assessment is the Minimum Data Set (MDS), a standardized instrument mandated by the CMS. Now in its third major revision, completion of the MDS 3.0 serves as the basis for the creation of an individualized treatment plan [7]. Data from the MDS are also used to determine reimbursement rates for Medicare fee-for-service (FFS) beneficiaries and to measure quality of care for both long- and short-term residents (table 1). A subset of these measures is posted on the CMS website, Nursing Home Care Compare, to help patients and families select a facility [8,9], and they are used in the calculation of the five-star rating. (See 'Quality of care in the SNF' above.)

A key component of the MDS is measurement of the individual's ability to perform activities of daily living (ADL), including transferring, ambulating, hygiene, toileting, communicating, and eating (table 2). For most short-stay patients, the focus is on achieving independence with these activities. The emphasis for long-term care residents is on preventing functional decline.

COMPONENTS OF CARE

Comprehensive geriatric assessment — Comprehensive geriatric assessment (CGA) includes an evaluation of the patient's functional, physical, cognitive, emotional, and psychosocial status. Ethical and goal-of-care issues must also be considered. A CGA can be a cost-effective intervention that improves quality of life in a variety of settings when recommendations are followed [10] and is recommended for use in frail older adults by the American Geriatrics Society [11]. The SNF is an ideal environment in which to carry out a CGA since its population is at high risk and the length of stay is relatively long, even for short-term rehabilitation patients. In fact, a comprehensive assessment as well as periodic reassessments are required by law in the form of the Minimum Data Set (MDS). (See "Comprehensive geriatric assessment".)

Rehabilitation — Postacute patients are typically expected to make gains in function and therefore usually receive some combination of physical therapy, occupational therapy, or speech therapy.

●Physical therapists – These therapists focus on strength, flexibility, and mobility, including ambulation with and without assistive devices as well as wheelchair mobility. Stair training and strategies to get in and out of a car are also provided when appropriate. Physical therapists can also be very helpful in managing pain that interferes with function and assessing exercise tolerance by measuring pulse oximetry and other vital signs.

●Occupational therapists – These therapists address functional capabilities largely involving the upper extremities, including hygiene, self-feeding, and dressing. They work together with physical therapists to address transfers to and from bed, chairs, and toilets. Occupational therapists also can provide a wide variety of devices to help with daily functioning and train patients and families in their use.

●Speech therapists – These therapists address safety in eating and swallowing by advising on food and beverage consistency as well as chewing and swallowing techniques. They also assist patients who suffer from cognitive and communication problems such as dysarthria, aphasia, or hearing impairment. They can help train facility staff, family, and home caregivers in techniques to optimize communication.

Recognition of new medical issues — To achieve home discharge, SNFs provide interdisciplinary care that incorporates physicians, advance practice clinicians, facility licensed nurses, therapists, nursing assistants, case managers, and social workers. Mental health clinicians and dietitians are often active members of the team as well. In addition to providing ongoing medical care for problems diagnosed in the acute-care hospital, and facilitating rehabilitation, SNFs must be alert for the occurrence of new problems. Nurses, recreation therapists, and certified nursing assistants (CNAs) will typically be the first staff members to recognize a new medical problem. Changes in the ability to perform activities of daily living (ADL) or cognitive changes may be early warning signs of an evolving medical issue. Family members or other loved ones often notice subtle early changes in condition as well. Close communication with the attending clinician is important to assure that new acute medical conditions, drug side effects, or psychiatric issues such as depression are addressed rapidly and effectively. The Interventions to Reduce Acute Care Transfers (INTERACT) program has a variety of tools that facilitate these processes [12].

Anticipating needs after discharge — In addition to optimizing function and medical care, the interdisciplinary team must prepare the resident and caregivers for a safe and successful transition to a home environment by identifying needed home supports. Support may be provided by the family or other care partners and may also involve agencies such as home health agencies and Area Agencies on Aging and Disability. Caregiver education is a crucial aspect of preparation for discharge to a home setting, with an emphasis on how to monitor and manage the patient's medical conditions, how to administer medications, and how to support with ADL such as safely assisting with transfers. Medicare will pay for devices deemed necessary for safe and effective functioning. A home visit before discharge is frequently helpful in identifying such needs, but when this is not possible, a "virtual visit" or photos/videos can also be helpful to SNF staff.

Family meetings — Family care planning meetings are an important component of SNF care. Care planning meetings are recommended within the first few days of SNF admission. Additional meetings can be helpful for short-stay patients with complex medical and/or psychosocial care needs prior to discharge, or whenever there is a significant change in condition in a long-stay resident. Families or other care partners are asked to participate in care planning meetings on a quarterly basis for long-stay residents [13]. Such meetings serve as a means of learning and sharing information and can facilitate medical decision making and advance care planning. Whenever possible, the patient/resident and surrogate decision makers should attend the meeting along with key staff, including representatives of the rehabilitation team, nursing, and social service along with the attending clinician (physician, nurse practitioner, or physician assistant). Many facilities are now able to conduct these meeting virtually, which can enhance participation by family members or care partners who are not living locally.

A useful format for these meetings includes the following steps:

●Review of the current medical situation to be sure that clinicians, the patient/resident, and family have the same understanding

●Review of advance directives currently in place, including whether the patient/resident is capable of making their own care decisions, the name of the surrogate decision maker, and any agreed-upon treatment preferences

●Review of treatment options, including an explanation of what can be done at home, in the SNF, and at the hospital

CLINICAL ISSUES — 

Evidence-based interventions and guidelines have generally been developed in younger, community-dwelling populations. Thus, guidelines for best practice may be challenging to apply in the SNF setting. Short-stay patients are often in a period of medical instability and require very careful management and monitoring to ensure optimal recovery and minimize the risk of adverse events. They may also have postoperative pain and wounds that need careful monitoring and frequent adjustments to medications and the care plan. Directly applying evidence and practice guidelines to SNF residents who are frail and have limited life expectancy can have unintended negative consequences. Specific examples include the overtreatment of hypertension, which may contribute to falls and syncope, and the overtreatment of diabetes, which can result in recurrent episodes of hypoglycemia. Clinicians working in SNFs must use a person-centered approach to multimorbidity in order to prevent polypharmacy and diagnostic and therapeutic interventions that may cause more harm than good [14].

Vision and hearing — Impairments in vision and hearing are potentially reversible causes of impaired function and quality of life in SNF residents. These impairments are also associated with falls and their complications. Uncorrected hearing loss is associated with incident dementia and worsening of already impaired cognitive functioning [15].

●All residents should undergo the simple vision-screening assessment included in the Minimum Data Set (MDS). Residents who demonstrate moderate visual impairment or worse should undergo formal vision testing by an optometrist or ophthalmologist, unless they would not be expected to benefit from intervention due to severe dementia or other comorbidities. (See 'The Minimum Data Set' above.)

●Residents should undergo a hearing screening test using the whisper test and, when feasible, audiologic evaluation for a hearing aid if the screening test is positive. (See "Evaluation of hearing loss in adults".)

Simple remedies for visual impairment, such as finding a missing pair of glasses, can facilitate rehabilitation for short-term patients. In other patients, testing for refractive errors and supplying glasses to correct vision improves measures of quality of life and symptoms of depression at two months [16]. Caution should be used in prescribing bifocals as they have been particularly associated with falls [17]. (See "Geriatric health maintenance", section on 'Vision screening'.)

In addition, cataract surgery in SNF residents can lead to significant improvements in vision, psychological distress, and social interaction when compared with matched controls [18]. A comprehensive vision-restoration rehabilitation program introduced in a random sample of nursing homes led to a higher rate of cataract surgery in eligible residents compared with usual care facilities (31 versus 2 percent) [19].

Readily reversible causes of hearing impairment, such as impacted cerumen, should be corrected. Hearing impairment is found in 70 to 90 percent of older adult SNF residents [17]. Uncorrected hearing impairment adversely affects quality of life by leading to depression, cognitive impairment, and social isolation. In the SNFs, many individuals who have hearing aids are unable to use them independently and rely on assistance from certified nursing assistants (CNAs). Many residents with hearing impairment have not been evaluated for a hearing aid. In part, this reflects inadequate insurance coverage. Medicare pays for 80 percent of the cost of a hearing evaluation but does not cover hearing aids; Medicaid pays some or all of the cost of a hearing aid in 31 states [20,21]. Simple amplification devices (eg, a "pocket talker") can be extremely helpful to facilitate one-on-one or small group conversations in those with severe hearing impairment. (See "Presbycusis" and "Hearing amplification in adults".)

Cognitive issues — Routine screening of new admissions for cognitive issues is recommended. In addition, it is important to obtain information from the family and other caregivers regarding the patient's prior cognitive status. Both the Confusion Assessment Method (CAM) to screen for delirium and the Brief Interview for Mental Status are included in the MDS 3.0 and can be used to screen for cognitive impairment. The MDS can also be used to measure the Cognitive Performance Scale (CPS), which rates dementia on a scale of one (borderline intact) to six (very severe impairment). (See "The mental status examination in adults", section on 'Mental status scales or inventories' and 'The Minimum Data Set' above.)

The diagnosis of dementia must be made very cautiously at the time of admission for postacute care. Residual delirium from the hospital stay, disorientation due to environmental changes, instability of medical conditions, and the effects of medications complicate the diagnosis of dementia.

Dementia — Dementia is widespread in the SNF setting, with 60 to 90 percent prevalence overall. The prevalence is lower (closer to 40 percent) in postacute care patients [22,23].

●Mild to moderate dementia – Treatment for cognitive symptoms due to dementia is controversial [24,25]. One rationale for a trial of therapy, to maximize the potential that a patient continues to be able to live in the community setting, becomes moot once patients are admitted for long-term care but may be important for short-stay patients to maximize the likelihood of home discharge. However, cholinesterase inhibitors and/or memantine can have adverse effects, and there is limited value in treatment. A discussion of pharmacologic options for dementia treatment is presented separately. (See "Treatment of Alzheimer disease" and "Cholinesterase inhibitors in the treatment of dementia".)

The treatment of dementia-related behavioral symptoms (agitation, wandering, aggression, and other symptoms) is often difficult in the SNF environment and is discussed separately. (See 'Behavioral issues associated with dementia' below.)

●Advanced dementia – Advanced dementia (CPS five to six on the MDS) is a terminal illness with a poor short-term prognosis. (See "Care of patients with advanced dementia".)

Enrollment of patients with advanced dementia in hospice is sometimes problematic, given the difficulty of predicting six-month mortality [26]. However, adoption of a palliative approach to care is both feasible and advisable even when patients are not referred for hospice care. Discontinuing medications that are unlikely to provide benefit can decrease costs of care and risk of adverse effects [27]. (See 'Hospice and palliative care' below.)

Delirium — Delirium is a geriatric syndrome present in over one-third of hospitalized older adult patients and in 16 percent of all patients admitted to SNFs [28,29]. Delirium is associated with adverse outcomes in SNF patients, including higher 30-day mortality and hospital readmission rate, and lower likelihood of home discharge and physical function improvement [30].

Primary prevention of delirium is best-practice care [31]. An observational prospective study of delirious hospitalized patients showed that factors related to worsening delirium severity include the number of room changes, the absence of a clock or watch, the absence of reading glasses, and restraint use [32]. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Prevention'.)

Delirium can persist for months in some patients and become a chronic condition. In one study of 551 patients admitted to 55 rehabilitation hospitals and 30 SNFs in 29 states, 23 percent of patients had delirium on admission and, at one week, only 14 percent of the cases of delirium had resolved [33]. The percentage of short-stay SNF patients with delirium two weeks after admission is one of five quality measures publicly reported by the Centers for Medicare and Medicaid Services (CMS) [34]. Failure to resolve delirium may necessitate that short-term patients transition to long-term care.

●Screening and recognition – New admissions to SNFs are screened for delirium utilizing the CAM (table 3), which has been incorporated into the MDS 3.0 [35]. (See "Diagnosis of delirium and confusional states", section on 'Recognizing the disorder'.)

The signs and symptoms of delirium can be subtle and transient, making detection difficult. This can be especially problematic for new admissions to SNFs when staff may be unaware of the baseline status of patients and thus not realize that cognitive, behavioral, or functional changes are new. Patients with delirium can be incorrectly thought to have dementia, depression, psychosis, or even "normal" aging. Clinicians in SNFs should incorporate observations of facility staff as well as the family members of patients in order to identify and monitor delirium.

Patients are often transferred from SNFs to emergency departments for evaluation of symptoms related to delirium (eg, "altered mental status"). While transfer can provide rapid medical assessment, it is a source of disruption and stress to patients/residents, especially those with dementia. Additionally, it can be difficult for clinicians not familiar with the individual to assess for significant changes in cognition. While delirium is often described as a medical emergency and prompt evaluation is needed, consideration should be given as to whether a delirium evaluation can be performed by medical staff within the nursing facility using onsite laboratory and radiograph services. The Interventions to Reduce Acute Care Transfers (INTERACT) program contains a care path and other decision-support tools for the evaluation and management of altered mental status without transfer to the hospital when safe and feasible [12].

●Management – Pharmacologic management of delirium needs to be tailored to the symptoms. Reviews have documented the lack of effectiveness of antipsychotics for the treatment of delirium in the hospital setting, and these data can be extrapolated to the SNF setting as well [36,37]. More severe symptoms may require the use of antipsychotic medications when the individual is clearly psychotic, resisting needed care, or a danger to themselves or others. Whether atypical antipsychotics are more effective than typical antipsychotic medications in delirium management remains uncertain [38]. Antipsychotic agents are considered chemical restraints and their use is carefully scrutinized in the SNF setting. Supportive documentation for their appropriate use must be provided on an ongoing basis in the medical record. Benzodiazepines should generally be avoided unless the delirium is specifically caused by alcohol or benzodiazepine withdrawal. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis" and "Second-generation and other antipsychotic medications: Pharmacology, administration, and side effects".)

Behavioral issues associated with dementia — Management of behavioral disorders in the SNF is a common challenge, whether arising from longstanding mental illness or dementia. Misuse of psychotropic medications in older adults to address these issues leads to frequent adverse effects and deteriorating medical and cognitive status. To combat this problem in the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA–87), mandated freedom for every nursing home resident from medically unnecessary "physical or chemical restraints imposed for purposes of discipline or convenience." Measurement of restraint use is a CMS quality indicator for long-term residents. Nonetheless, the use of antipsychotic medications in nursing homes is common [39]. While studies of nonpharmacologic therapies for behavioral issues in long-term care have shown promise, they typically require specialized staff, staff trainings, and/or additional time commitments from staff, creating challenges to widespread implementation [40]. Dementia training for nursing facility staff is now a requirement in some states [41].

Agitation and psychotic symptoms — Over 80 percent of patients with dementia develop neuropsychiatric symptoms at some point during the course of their disease [42]. Agitation may be due to the dementia itself or to delirium in the setting of a reversible medical condition, such as pain, stroke, myocardial infarction, or infection, and clinicians should investigate the possibility of a medical cause for agitation [43,44]. Once acute medical problems have been excluded, clinicians should consider empirical treatment of pain [45].

Delusions and hallucinations in patients with dementia are specific indications for the prescription of antipsychotic medications, although their use is a CMS quality indicator for both short- and long-term SNF residents. Gradual dose-reduction trials are required and should be carefully documented. The choice of agent and use of these medications is discussed in detail separately. (See "Management of neuropsychiatric symptoms of dementia", section on 'Antipsychotic drugs' and "Second-generation and other antipsychotic medications: Pharmacology, administration, and side effects".)

When prescribed, clinicians should inform the resident (when appropriate), the family, and caregivers of the mortality risk associated with antipsychotic medications in older adults and decide with them whether to proceed with treatment (see "Management of neuropsychiatric symptoms of dementia", section on 'Mortality risk'). These discussions should be clearly documented in the SNF record.

Although gabapentin use for agitation and psychotic symptoms has risen dramatically, probably largely in response to CMS initiatives to reduce inappropriate antipsychotic use, there is no evidence that this drug is helpful in treatment of behavioral symptoms of dementia, and it can cause sedation [46]. (See "Management of neuropsychiatric symptoms of dementia", section on 'Drugs with uncertain benefit'.)

Aggressive behavior — Aggressive behavior develops in 20 to 57 percent of individuals with dementia [47]. Such behavior is particularly troubling in the SNF where other residents, such as roommates, are impacted and staff may be at risk for injury. A useful framework for clinicians to use in responding to patients with dementia exhibiting aggressive behavior is as follows [48]:

●Assess the danger of the situation to the patient and others

●Establish an etiology of the symptoms

●Determine how severe and frequent the symptoms are

●Explore past treatments and caregiver strategies for similar problems that have been effective

●Institute nonpharmacologic strategies for behavior management if no underlying medical cause discovered

●Discuss with the patient's surrogate decision maker the risks and benefits of pharmacologic treatment

●Regularly assess and document the response to pharmacologic treatment, monitor for adverse reactions, and titrate to the lowest effective dose; consider a trial off of the medication if symptoms have been well controlled for three to six months

While the documented benefit of nonneuroleptic medication in this setting is limited, several nonpharmacologic strategies have been effective, including music therapy, cognitive stimulation therapy, and behavioral management therapy [48]. Caregiver education to help the staff manage difficult situations is paramount. (See "Management of neuropsychiatric symptoms of dementia".)

Wandering — Wandering or exit-seeking behavior are difficult issues for SNFs because of potential risks to the resident. Patients who simply enjoy walking in the facility and do not intend to leave the premises are frequently labeled "wanderers." Creative approaches to allowing the patients freedom of movement without endangering their security include the use of door alarms, magnetized identification bracelets, enclosed patios, and circular corridors that promote contained walking.

Psychotropic medications — There is an increased focus on the appropriate use of psychotropic medications in SNFs, including antidepressants, antipsychotics, anti-anxiety medications, and hypnotic medications. In some states, SNFs are required to obtain consent from the patient or the durable power of attorney when these medications are administered. Consent forms and medication orders need to include dose ranges for each psychotropic medication being administered. Patients and residents treated with antipsychotic medications must be monitored for extrapyramidal side effects. In addition, the indication for psychotropic medication use should be regularly reassessed; an attempt at gradual dose reduction is required and should be documented in the SNF record. (See 'Agitation and psychotic symptoms' above.)

Depression — Screening for depression should be carried out on all SNF residents using validated measures [49,50]. The MDS includes the Patient Health Questionnaire (PHQ)-2 and PHQ-9 and can be used for this purpose. Other tools are available, such as the short version of the Geriatric Depression Scale, which takes 5 to 10 minutes to administer and is appropriate for those with no more than minimal cognitive impairment [49]. The Cornell Scale for Depression in Dementia is appropriate for those with cognitive impairment (table 4) [50]. (See "Diagnosis and management of late-life depression", section on 'Screening'.)

Untreated depression in the postacute setting can decrease motivation, resulting in lack of participation in the rehabilitation program, thus impacting SNF length of stay and impeding the likelihood of successful discharge to home. In the residential setting, depression impairs quality of life by causing social isolation, loss of interest in usual activities, and problems with eating and sleeping.

A prior history of depression should be ascertained in all SNF residents as those with a history of depression are at risk of recurrence and should be considered for long-term maintenance therapy [51]. (See "Depression in adults: Course of illness", section on 'Recurrence'.)

Many antidepressants are associated with falling, and the choice of agent should be individualized [52]. Treatment of depression in older adults is discussed elsewhere. (See "Diagnosis and management of late-life depression", section on 'Management'.)

Falls — Falls are a common problem in the SNF, with the mean incidence of falls reported to be 1.5 falls per bed per year [53]. The fall rate is a CMS quality indicator for long-term residents [54]. The cause is often multifactorial, with intrinsic factors such as gait disorders, visual impairment, and impaired judgment due to dementia as well as extrinsic factors such as environmental hazards and medications contributing. It is essential to exclude iatrogenic hypotension and postural hypotension as preventable causes of falls. Volume depletion from diuretics or low fluid intake can compound this risk factor. A meta-analysis of fall prevention programs in SNFs did not show a significant effect on the overall incidence of falls, although it did significantly reduce the number of recurrent fallers [55]. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in nursing care facilities and the hospital setting".)

Deaths in patients who have had a fall may require reporting to the medical examiner/coroner. (See "Death certificates and death investigations in the United States", section on 'Deaths reportable to medical examiner/coroner' and "Death certificates and death investigations in the United States", section on 'Considerations for special populations'.)

Infections — In the SNF, infection is one of the leading causes of morbidity, mortality, and readmission to the acute care hospital. (See "Outbreaks in long-term care facilities: Detection and management".)

SNF residents are at high risk of contracting a variety of infections because of impaired immune defenses, multiple comorbidities, nutritional deficiencies, and exposures within the SNF environment. In addition, patients with advanced dementia or multiple strokes often have impaired swallowing, which puts them at high risk of aspiration pneumonia. (See "Approach to infection in the older adult", section on 'Increased risk for infection'.)

Age-appropriate immunizations for influenza, COVID-19, pneumococcus, herpes zoster, and tetanus-diphtheria should be administered to all SNF patients (as indicated). The respiratory syncytial virus (RSV) vaccine should also be considered. Despite diminished vaccine efficacy in the SNF population, vaccination will help to both prevent infection in the immunized patient and prevent spread of infection within the institution [56]. (See "Standard immunizations for nonpregnant adults".)

Clinicians must be aware of the epidemiologic challenges posed by SNFs. While the benefits of antibiotic treatment to the patient may be small, the public health risk of fostering antibiotic resistance with treatment may be considerable. Inappropriate antibiotic use in SNFs contributes to higher rates of antibiotic-resistant pathogens (eg, methicillin-resistant Staphylococcus aureus, multidrug resistant organisms, and vancomycin-resistant Enterococcus) and to antibiotic-induced Clostridioides difficile colitis [57]. (See "Outbreaks in long-term care facilities: Detection and management", section on 'Antimicrobial-resistant organisms'.)

SNFs are increasingly implementing antibiotic stewardship programs to reduce the incidence of resistant organisms, antibiotic-associated drug interactions, and C. difficile infections [58]. Federal conditions for participation in the Medicare program require SNFs to identify an infection control practitioner and implement an antibiotic stewardship program. Many resources are available for these programs [59]. (See "Principles of infection prevention and control in long-term care facilities".)

Evaluation for infection — Several factors may compromise the recognition of infection in SNF residents, including communication difficulties, medical comorbidities, and atypical presentations. Fever, as typically defined (temperature >100.4°F [38°C]), is absent in more than 50 percent of nursing home patients with serious infection [57]. (See "Approach to infection in the older adult", section on 'Fever definition'.)

Infection should be suspected in SNF residents who exhibit the following signs and symptoms [57]:

●New or increasing confusion, incontinence, deteriorating mobility

●Decreased food intake

●Change in behavior (eg, agitation, aggressiveness)

2008 updated guidelines from the Infectious Diseases Society of America suggest the following parameters for defining a fever in patients in SNFs [57]:

●A single oral temperature >100°F (37.8°C); or

●Repeated oral temperatures >99°F (37.2°C) or rectal temperatures >99.5°F (37.5°C); or

●An increase in temperature of >2°F (1.1°C) over baseline

Initial evaluation, often by nursing staff, should include assessment of respiratory rate, hydration, mental status; skin inspection; and evaluation of oropharynx, chest, heart, abdomen, and catheter if present.

Advance directives should be reviewed prior to further assessment. A reasonable limited workup includes a complete blood count, with differential cell counts, if consistent with the resident's treatment preferences. Blood cultures generally have a low yield and should be performed only when bacteremia is highly suspected. Pulse oximetry should be done for patients with tachypnea (respiratory rate >25 breaths per minute) or other respiratory signs and symptoms. Chest radiography should be ordered when hypoxemia is present (oxygen saturation <90 percent) or suspected.

COVID-19 — The COVID-19 pandemic caused substantial morbidity and mortality in the SNF setting. The epidemiology and clinical characteristics of COVID-19 are presented elsewhere. (See "COVID-19: Epidemiology, virology, and prevention" and "COVID-19: Clinical features" and "COVID-19: Diagnosis".)

Features of the clinical presentation unique to older adults are also discussed separately. (See "Approach to infection in the older adult", section on 'COVID-19'.)

Patients who develop COVID-19 in the nursing home setting should be evaluated to determine the severity of disease and need for emergency department evaluation or hospitalization. (See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Clinical evaluation and triage' and "COVID-19: Management in hospitalized adults".)

Many patients will not require hospitalization and can be managed in the SNF setting. For such patients, treatment options include supportive care and antiviral agents or monoclonal antibodies. These treatment strategies and the data supporting their use are discussed in detail in a separate topic review. (See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Symptom management and recovery expectation' and "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Therapies with limited role or uncertain benefit'.)

During periods of high level of community transmission, certain measures may be implemented to prevent introduction and spread of COVID-19, including visitor restrictions, universal masking, and screening staff members for symptoms prior to entering the facility [60-62]. (See "Outbreaks in long-term care facilities: Detection and management", section on 'SARS-CoV-2'.)

Influenza — Influenza virus is typically brought into the SNF by staff or visitors and spreads rapidly among the residents who share rooms and eat in a communal dining room. Hospitalization rates rise during epidemics as SNF residents may develop cardiac complications, principally myocardial infarction and congestive heart failure, and pulmonary complications, particularly bronchospasm and pneumonia. In addition, SNF residents affected with influenza infection experience a subsequent decline in functional status, including a decrease in independence in bathing, dressing, and mobility [63].

Every effort should be made to vaccinate residents against influenza in the early fall. For both long- and short-term residents, the influenza immunization rate is a CMS quality indicator. Vaccination of SNF staff has also been particularly effective in preventing resident morbidity and mortality [64]. (See "Principles of infection prevention and control in long-term care facilities".)

Emergence in the United States of influenza strains resistant to amantadine and rimantadine has led to the CDC recommendations for use of neuraminidase inhibitors zanamivir (inhaled) and oseltamivir (oral) for the treatment and prevention of both influenza A and B [65-67]. Treatment doses and prophylactic use of neuraminidase inhibitors are discussed separately. (See "Seasonal influenza in nonpregnant adults: Treatment" and "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention".)

Additional infection control measures should be instituted in the event of an influenza outbreak. (See "Infection control measures for prevention of seasonal influenza", section on 'Infection prevention in the health care setting' and "Outbreaks in long-term care facilities: Detection and management", section on 'Influenza'.)

Clostridioides difficile — C. difficile, another organism to which SNF residents are particularly prone, presents an infection control challenge [68]. Debilitated residents who are treated with broad-spectrum antibiotics are highly susceptible to developing C. difficile diarrhea. The organism forms spores that can survive for considerable periods on fomites, thereby leading to high transmission rates. Fecal incontinence and poor personal hygiene compound the risk of spread. (See "Outbreaks in long-term care facilities: Detection and management", section on 'Clostridioides difficile'.)

The diagnosis and treatment of C. difficile are discussed elsewhere. (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis" and "Clostridioides difficile infection in adults: Treatment and prevention".)

Asymptomatic bacteriuria — Asymptomatic bacteriuria can be found in approximately 50 percent of female and 33 percent of male SNF residents. A variety of factors predispose older adult patients to develop urinary tract colonization [69]:

●Dementia

●Physical inability to get to the toilet

●Neurologic processes affecting the bladder

●A general rise in the incidence of urinary tract infection (UTI) with age that starts in childhood and continues throughout life

●Poor perineal hygiene, especially when fecal soiling is present

Diagnostic criteria for bacteriuria in older adults are the same as those for younger individuals. However, the presence of pyuria is not specific for UTI in older SNF patients [70]. (See "Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults".)

The treatment of asymptomatic bacteriuria in older adults does not prevent symptomatic infection, improve urinary function, or enhance survival. Published consensus guidelines are very helpful and strongly support only treating bacteriuria when lower urinary tract symptoms are present [43,44]. (See "Asymptomatic bacteriuria in adults" and "Approach to infection in the older adult", section on 'Urinary tract infection'.)

Urinary tract infection — UTIs are the most common source of bacteremia, and the most common reason for antibiotic use in nursing homes [71-73]. Risk factors include urinary catheters, benign prostatic hypertrophy and prostatitis, atrophic vaginitis and estrogen deficiency in women, diabetes, neurogenic bladder, dementia, dehydration, and functional impairment [74-77]. Nursing home residents with a chronic indwelling catheter are more likely to have multidrug-resistant organisms than residents without those devices [78].

Important steps for prevention of catheter-associated UTI include avoidance of unnecessary catheterization, use of sterile technique for catheter placement, and prompt removal of the catheter. (See "Catheter-associated urinary tract infection in adults", section on 'Prevention'.)

Pneumonia — Pneumonia occurring in the SNF setting is referred to as "nursing home-associated pneumonia" (NHAP) and is a leading cause of death in SNFs. Residents with advanced dementia, severe Parkinson disease, or other neurologic conditions are at high risk for aspiration pneumonia. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Aspiration pneumonia in adults".)

Immunization with the pneumococcal vaccines is recommended for all individuals who meet specified criteria and who do not have evidence of adequate vaccination, unless the goal of care is exclusively to maintain comfort. The rate of pneumococcal vaccination is a CMS quality indicator for SNFs. (See "Pneumococcal vaccination in adults".)

Several studies have identified the importance of oral hygiene for the prevention of pneumonia in older adult (>65 years of age) SNF residents [79-82]:

●In a prospective study of 613 nursing home residents followed for one year, 112 (18 percent) developed radiographically documented pneumonia [79]. Inadequate oral care (hazard ratio [HR] 1.55) and swallowing difficulty (HR 1.61) were independently associated with pneumonia.

●The importance of oral care in preventing pneumonia and pneumonia death was illustrated in a trial of 417 patients (average age 82 years old) who were in a SNF and at baseline had poor oral health [80]. Residents were randomly assigned to an oral care group (including nurses or caregivers brushing the teeth after every meal and hygienists providing professional care once per week) or no oral care. During two years of follow-up, patients in the nonoral care group had a significantly higher incidence of pneumonia (19 versus 11 percent in those receiving oral care, relative risk [RR] 1.67, 95% CI 1.01-2.75) and, among those who developed pneumonia, a higher incidence of death due to pneumonia (16 versus 7 percent, RR 2.40, 95% CI 1.54-3.74). The benefits of oral care were evident whether the patient had teeth or was edentulous.

Pneumonia can often be successfully treated in the SNF, with two studies showing comparable outcomes to patients treated in the hospital [83,84]. One of these studies showed that implementation of a clinical care pathway decreased hospitalizations by a mean of 12 percent [84]. Details of this pathway are presented separately. (See "Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care", section on 'Nursing home residents'.)

Obtaining a bacteriologic diagnosis of pneumonia is impossible in most SNF patients; thus, initial treatment is usually empiric. The most common bacterial pathogen causing NHAP is Streptococcus pneumoniae, with S. aureus and enteric gram-negative organisms commonly found in the sickest patients [85]. (See "Treatment of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Empiric therapy'.)

Tuberculosis — Screening for latent tuberculosis infection (LTBI) among individuals in SNFs has been a routine practice in the past [86]; subsequently, enthusiasm for routine testing and treatment of LTBI has waned [87]. The indications and approach for LTBI testing are discussed separately; no modifications to this approach are needed for patients in long-term care facilities (see "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)"). Outbreaks of tuberculosis in long-term care settings are discussed separately. (See "Outbreaks in long-term care facilities: Detection and management", section on 'Tuberculosis'.)

Infection in SNF residents with advanced dementia — The prognosis of infection in SNF residents with advanced dementia is poor. Initiating antibiotic treatment in patients with advanced dementia may not achieve either the goal of life prolongation or amelioration of symptoms [88,89].

Regardless of the site of treatment, the long-term prognosis for residents with advanced dementia who develop pneumonia is poor: one study found a 53 percent six-month mortality, compared with 13 percent in cognitively intact older adults [90]. One prospective observational study found that SNF residents with advanced dementia who received antibiotic treatment for pneumonia had longer survival but lower scores on measures of comfort than those who were not treated for pneumonia [91]. This suggests that, among those residents with advanced dementia for whom comfort is the overriding goal of care, it is appropriate to withhold antibiotics and focus on palliative care. When antibiotics are elected, oral administration and treatment in the SNF may be more consistent with the goals of care than intravenous (IV) antibiotics or hospital care.

Tube feeding, which is sometimes recommended for SNF residents with recurrent aspiration pneumonia, has not been shown to prevent aspiration [92] (see "Gastrostomy tubes: Uses, patient selection, and efficacy in adults"). Instead, the clinician should recommend palliative care in the nursing home setting. (See 'Hospice and palliative care' below.)

Pain — Pain is common in the SNF setting and is often undertreated. One cross-sectional study of 49,971 residents found daily pain in 26 percent of nursing home patients, of whom almost one-quarter received no treatment [93]. Pain can be persistent, acute, or related to end of life.

●Persistent pain, often caused by arthritis, is present in up to 80 percent of SNF residents [94].

●Acute pain related to a new medical or surgical condition is especially prevalent in short-term patients recently discharged from the hospital. Patients with postoperative pain represent a significant subset of this population.

●Pain at the end of life is common in the SNF, which is the site of 25 to 30 percent of all deaths. Malignancy is a common cause for pain at the end of life, but other conditions have been shown to cause similar distress [94].

Undertreated pain places SNF residents at risk for a myriad of complications, including depression, weight loss, delirium, functional decline, and skin breakdown. This supports the current use of self-report of moderate to severe pain as a CMS quality indicator in the SNF setting. Factors that contribute to uncontrolled pain in SNFs include using pain medications with insufficient potency and/or inadequate frequency of administration, particularly for patients recently transitioned from parenteral to oral medications. Postacute patients typically require physical and occupational therapy, which can result in increased pain as activity increases.

●Assessment – Even those with moderately severe cognitive impairment are able to identify if they have experienced pain in the preceding five days. Accordingly, MDS 3.0 incorporates resident interviews in the assessment of pain and measures the impact of pain on quality of life by asking whether pain has impaired sleeping or day-to-day activities [95]. When pain does impact these activities, therapeutic interventions should be considered, but the response to those interventions should be carefully assessed and monitored. Interventions should only be continued if they are effective and are not causing significant adverse reactions. An algorithm may be helpful in assessing pain in SNF residents with severe cognitive impairment (algorithm 2).

●Management – Many nonpharmacologic approaches can be effective in managing pain, especially chronic pain associated with arthritis in the SNF population. These include heat, cold, massage, stretching, and strengthening among several others [96]. When drug therapy is needed, all three types of pain should be treated using the World Health Organization pain ladder, a three-step approach that uses nonopioids, weak opioids, and strong opioids coupled with adjuvant medications where appropriate [97].

Patients/residents with pain should be assessed as to whether pain medications should be given "as needed" or on a scheduled basis and whether long- and/or short-acting preparations should be used. Patients with cognitive impairment who have persistent pain should be given scheduled analgesics as they commonly do not request as-needed medication when they may benefit from it. Persistent pain should also be managed using scheduled rather than as-needed medications and incorporate nonpharmacologic modalities.

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in this population carries substantial risks and should be avoided [98]. Hence, acetaminophen and weak opioid analgesics are preferred over NSAIDs for most patients. In our experience, in addition to nonpharmacologic interventions, topical NSAIDs and lidocaine patches may be very helpful in the management of persistent pain and acute worsening of arthritic symptoms, and in patients/residents with both pain and symptoms of depression, a careful trial of duloxetine, which is indicated for both conditions, may be beneficial.

Anticipating the loss of bowel motility caused by opioids is essential. Bowel medication programs may need to be adjusted with escalations or reductions in opioid doses. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Opioid bowel dysfunction'.)

Postacute patients typically have conditions that are expected to improve. Ongoing assessment needs to be made regarding optimal timing for gradual dose reduction of pain medications. Planning how opioids will be administered and tapered after discharge is essential and must be coordinated with the clinicians who will assume care post discharge.

Patients near the end of life may be unable to take oral medications, necessitating that pain medications be administered via alternate routes. Transdermal and sublingual preparations of opioids can be particularly useful. Acetominophen and opioids can also be administered rectally. While subcutaneous injections can often be used in SNFs, the duration of pain relief tends to be shorter than with oral or transdermal preparations, with an increased likelihood of suboptimal pain control. While some facilities are able to give pain medications via subcutaneous infusion pumps, most are not. (See "Palliative care: The last hours and days of life", section on 'Pain'.)

Staff resistance to opioid administration at the end of life is often related to fears of causing harm to the patient. Strong clinician and facility leadership coupled with educational programs for staff are essential to provide effective pain management to this population. In addition, hospice involvement can provide additional support and expertise in managing pain.

Nutrition and hydration — Both short-term patients and long-term SNF residents are particularly vulnerable to difficulties maintaining adequate nutrition and hydration. Patients admitted from the acute-care hospital setting are at risk for weight loss because they may have been "nothing by mouth" or on a restricted diet in the hospital for significant periods of time. In addition, delirium, pain, and gastrointestinal disorders can impact nutritional status. Institutional settings may not provide food choice offerings that match patient preferences. Chronic illness, depression, and medication side effects can further cause or contribute to anorexia and weight loss [99]. Long-term SNF residents often have chronic, progressive illnesses that impact appetite, chewing, swallowing, and digestion.

The CMS standards dictate that every SNF resident should be provided with sufficient food and fluids to maintain proper nutrition and hydration. Significant weight loss is a CMS quality indicator for nutrition and hydration in long-term SNF residents. Assessment for weight loss is part of the MDS quarterly reassessment process. Unintentional weight changes of 5 percent in 30 days and 10 percent in 180 days require care plan review. Studies indicate that unintentional weight loss of 5 percent is a marker for a 5- to 10-fold increased risk of death [100].

Weight loss — SNFs should document whether weight loss is expected or is unintentional. In residents who are terminally ill, weight loss may be unavoidable and palliative treatment plans should be in place indicating that low oral intake and weight loss is expected. If unintended weight loss is present, the resident should be assessed for remediable causes. The interdisciplinary team is important in the prevention and management of weight loss. SNFs have registered dieticians who perform nutritional assessments and can make recommendations regarding diet and the use of nutritional supplements. The Mini-Nutritional Assessment can identify patients with, or at risk for, malnutrition with 96 percent sensitivity and 98 percent specificity [101].

Interventions — Interventions related to weight loss and optimizing nutrition need to be integrated with the patients' overall goals and a well-documented plan of care.

●Skilled therapy – Interventions by speech therapists, occupational therapists, or behavioral health clinicians may be indicated, depending on the etiology of the weight loss. Dysphagia, for example, is commonly associated with neurologic problems such as Parkinson disease, Alzheimer disease, or stroke. SNF patients may have oral infections (eg, thrush), inflammation related to radiation therapy, or dentures that are misplaced or ill fitting.

Speech therapists can identify the most appropriate food consistency and can work with patients to optimize chewing and swallowing techniques. Impaired dexterity, whether due to arthritis, stroke, or a recent fracture, can make it difficult for patients to use utensils. Occupational therapists can teach patients to use assistive devices such as utensils with thickened handles that are easy to grasp. Nursing assistants provide supervision, encouragement, and assistance with feeding. SNF staff members also teach family members and other caregivers how to manage these nutrition-related issues prior to discharge to home for short-term patients.

●Depression treatment – Depression is a major factor associated with malnutrition, and weight loss in older persons is a condition for which antidepressant medication is often indicated [102]. However, certain antidepressants (eg, SSRIs) can also cause anorexia or anticholinergic symptoms such as dry mouth and constipation (tricyclic antidepressants). Evidence suggests that mirtazapine may be more effective than SSRIs in promoting weight gain, most likely because its mechanism of action is both serotonergic and noradrenergic [103]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss'.)

●Supplements – Oral supplements are often used in the management of weight loss. A meta-analysis of 15 studies in malnourished older adult patients (including some patients in hospitals as well as SNF settings) found a small survival advantage for patients provided with liquid diet supplements compared with no specific nutrition treatment [104]. Factors that may interfere with the success of oral supplements in the SNF include inadequate nursing staff time to deliver and assist with the between-meal supplements, interference with calorie consumption at meals, and unrealistic dosing schedules [105]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Nutritional supplements'.)

●Other interventions – Megestrol acetate is an appetite stimulant that has been used in patients without a reversible etiology of weight loss. However, evidence of benefit is weak [106]. Because of potential adverse effects, megestrol acetate should not be used in most SNF residents. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Limited role for appetite stimulants'.)

Total parenteral nutrition (TPN) is sometimes advocated in the setting of weight loss. However, few SNFs have the clinical resources and expertise to manage TPN, and it is expensive. This modality of nutrition should be limited to short-term use for a reversible condition, and feeding via the gastrointestinal route should be restarted as soon as possible.

Long-term residents with advanced dementia often have difficulty chewing and swallowing. There is no evidence that percutaneous endoscopic gastrostomy tubes improve nutritional status or prolong life in the SNF resident with advanced dementia. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults" and "Care of patients with advanced dementia", section on 'Oral versus tube feeding'.)

Hydration — Older adult individuals are at increased risk of hypovolemia due to an impaired thirst mechanism and age-related reduction in renin and aldosterone production that results in increased renal excretion of salt and water. This risk is magnified in cognitively impaired SNF residents, who may be unable to articulate the experience of thirst, and in physically impaired residents, who may have difficulty procuring fluids. Medications such as diuretics further increase the risk of hypovolemia, especially when an acute medical condition diminishes appetite and fluid intake. Simple interventions such as regularly offering fluids to residents have been shown to significantly decrease the frequency with which dehydration develops [107].

The symptoms of hypovolemia in the nursing home population are often nonspecific, such as a change in mental status or falls. More specific signs of hypovolemia such as orthostatic hypotension, dry mucus membranes, hypernatremia, and prerenal azotemia are typically associated with more profound degrees of volume depletion [108].

SNFs vary in their capability to start and maintain IV therapy. When a decision is made to provide artificial hydration, subcutaneous fluid infusion (hypodermoclysis or clysis) is an underused alternative to IV therapy for treatment of mild to moderate hypovolemia. Clysis may be useful in SNFs without continuous availability of nurses or clinicians to insert or maintain an IV catheter for residents with poor veins or those who repeatedly remove IV lines secondary to agitation and in those on hospice or palliative care for symptom relief.

Pressure injury — The prevalence of pressure injury (formerly known as pressure ulcers) is an important quality indicator in SNFs. Pressure injury is often painful and increases the risk for reduced mobility, infection, and death in the SNF setting [109]. However, whether the pressure injury is an independent risk factor for mortality or a marker for underlying comorbidities is unclear. Most pressure ulcers do not reflect acute infection and do not warrant antibiotic therapy.

●Risk factors – SNF short-term patients and long-term residents are at risk for pressure injuries for a variety of reasons, including immobility after surgical procedures, impaired nutritional intake, sensory and cognitive impairment, and incontinence. Hip fractures and strokes can lead to pressure injuries of the heel, coccyx, and sacrum because of pain and reduced mobility. Physicians and advance-practice clinicians should help identify risk factors and alert care team members about potential preventive interventions.

●Assessment and documentation – Physicians and advance-practice clinicians should also examine patients with pressure injuries regularly, in addition to any wound care specialist who may be involved. Documentation in the medical record is critical in outlining the response to preventive and treatment measures.

MDS 3.0 requires assessment by SNF staff of patients for pressure injury based upon the Pressure Ulcer Scale for Healing tool. This tool standardizes documentation of pressure injuries based on location and size. In addition, pressure injuries are staged by a one to five grading system based upon the degree of penetration into underlying structures. When the wound bed cannot be adequately visualized because of slough, wounds are "unstageable." (See "Clinical staging and general management of pressure-induced skin and soft tissue injury", section on 'Clinical evaluation'.)

●Management – MDS 3.0 requires documentation of interventions put in place to manage pressure injury, including pressure-relieving devices, positioning and turning protocols, and specific wound treatments. Pressure injury management requires an interdisciplinary approach for which the SNF environment can be well-suited. Nurses; dieticians; nurse aides; physical, occupational, and speech therapists; and wound care consultants all have roles to play in pressure injury management.

A variety of products may be used in the care of pressure injury. Product choice is based upon the specific characteristics of the wound: the presence of slough, the amount of exudate, and the size and depth of the wound. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Vacuum-assisted closure devices are commonly used to assist with wound healing for both acute and chronic wounds. They decrease the need for frequent dressing changes but are costly. Few data indicate that they are superior to other commonly used modalities for the treatment of pressure injury. (See "Negative pressure wound therapy".)

Healing of wounds is thought to require higher protein intake over baseline, and pressure injuries are often associated with nutritional compromise. Coexisting medical issues that affect appetite and nutrient absorption can further increase risk. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Patients with terminal conditions may choose, or their families/loved ones may choose for them, to forgo interventions that could reduce the risk of pressure injury development or promote pressure injury healing. Examples include requests to minimize repositioning or decisions to decline surgical debridement or wound grafts.

Prevention of adverse drug events — Risk factors for adverse drug events among nursing home residents include taking opioids, antipsychotics, or antidepressants; taking more than nine medications; and multiple comorbidities [110]. Medication toxicity is a major cause of hospitalization in older adult patients [111]. All SNF facility staff need to be alert to common medication-related side effects such as altered mental status, falls, constipation, and functional decline. It is also important for facilities to have a culture that encourages the reporting of adverse drug events or medication errors so that systems can be improved. (See "Prevention of adverse drug events in hospitals".)

Age-related pharmacodynamic and pharmacokinetic changes increase the vulnerability of older adult SNF residents to adverse reactions from medications. In particular, enhanced central nervous system sensitivity to anticholinergic agents predisposes older patients to problems such as delirium, constipation, urinary retention, and gait instability. (See "Drug prescribing for older adults", section on 'Adverse drug events'.)

Polypharmacy — Polypharmacy is common among SNF residents and is a major risk for adverse drug reactions such as falling, delirium, and other geriatric syndromes [112,113]. Medication lists should be examined at every clinical visit for opportunities to optimize and deprescribe as appropriate. (See "Drug prescribing for older adults", section on 'Polypharmacy'.)

SNF patients often have multiple chronic diseases, each of which typically triggers a clinical algorithm designed to define optimal care. However, what is optimal for a patient with one disease is not necessarily optimal for someone with multiple conditions [114] (see "Multiple chronic conditions"). Further, standard guidelines for management of chronic conditions may not be appropriate for people near the end of life. For such patients, when there is not likelihood of benefit for treatments and/or the risks of treatment do not outweigh potential benefits, it is reasonable to avoid intensive treatment of diabetes, hyperlipidemia, and hypertension and to forgo preventive treatment of conditions such as osteoporosis and hyperlipidemia.

Care transitions accentuate the risks for polypharmacy. Patients often go from the hospital to the SNF with no explanation as to why certain medications are being given, why doses may have been changed, and what medications may have been purposely omitted. Nursing staff need to be encouraged to question orders if the indication for medications they are administering is unclear. Polypharmacy also results when the side effects of medication are interpreted as a new condition, which is then treated with an additional medication rather than by stopping or adjusting the dose of the offending medication. (See "Drug prescribing for older adults", section on 'Prescribing cascades'.)

An accurate medication list that reflects prehospitalization medications and changes made during the hospital stay may not be available when patients arrive at the SNF. Effective medication reconciliation is the gold standard for all SNF admissions. When medication dosing or indications are unclear, family members, other informal caregivers, prior clinicians, and pharmacies must be contacted for clarification. When available, electronic medical records should be reviewed.

Deprescribing — It is essential that new medications are monitored for effectiveness and, when ineffective, are eliminated. Clinicians should work collaboratively with pharmacist consultants and nursing staff to consider deprescribing medications that may no longer be necessary and potentially harmful and/or when multiple drugs in the same class are prescribed [115]. (See "Deprescribing", section on 'Deprescribing specific medications'.)

Clinicians should identify and document the "target symptoms" that are being treated when new medications are initiated. Clinicians should treat with the lowest possible therapeutic dose and discontinue medications if the response to the medication does not significantly reduce the target symptom.

In the SNF, pharmacy consultants review medication regimens and make recommendations to eliminate medications, modify dosages, or monitor parameters with clinical or laboratory tests [115]. Compared with usual care, involvement of a pharmacist to review medications on transfer from the hospital to the SNF and to communicate recommended changes to the attending clinician decreased the risk of a discrepancy-related adverse drug event [116]. In addition, a cluster-randomized trial found that a pharmacist-led medication review decreased the rate of delirium in SNF patients [117].

The issuance of monthly medication sheets serves as an opportunity for reviewing medication regimens on long-term patients. As the SNF patient's status changes, medications that were once appropriate may no longer be necessary. For example, a study in 22 nursing facilities in the Boston area found that 37.5 percent of patients with advanced dementia received at least one medication that was not appropriate in late dementia (most commonly acetylcholinesterase inhibitors and lipid-lowering agents) [27].

Discharges from the SNF to home provide another opportunity to review and optimize the medication regimen. Schedules should be practical, and patients or caregivers need to understand the indication and potential side effects of all medications. It is also important to be sure that patients can afford to buy their medications. Finally, the clinician(s) assuming care for the patient must receive an accurate medication list. (See "Deprescribing", section on 'Hospitalized patients'.)

Urinary and bowel issues

Urinary incontinence and overactive bladder — Urinary incontinence, affecting at least 57 percent of SNF patients [118], is associated with increased risk of hospitalization, UTI, falls, and pressure injuries and significantly impairs quality of life [119]. The development of urinary incontinence is a CMS quality indicator for long-term residents. Many other residents have overactive bladder, which includes frequency, nocturia, and urgency; it may or may not be accompanied by incontinence but still has the same impacts, especially risk of falling as patients attempt to rush to the bathroom.

Practice guidelines outlining an accepted approach to the diagnosis and management of incontinence [120] have been adapted for use in the SNF [121,122]. The diagnosis and treatment of urinary incontinence is discussed in detail separately. (See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment" and "Urinary incontinence in males".)

Issues of particular concern in the SNF setting include the following:

●Evaluating for potentially reversible conditions such as delirium, urinary retention, bladder infection, constipation, diabetes, excessive caffeine intake, or medications (eg, anticholinergics and diuretics).

●Instituting prompted voiding, which was found to be somewhat effective at short-term follow-up in reducing daytime incontinence in two systematic reviews of randomized trials involving SNF patients with cognitive impairment and urinary incontinence [123,124]. One study among long-term residents suggested a persistent benefit four months after the intervention period [125]. However, most trials used research staff to provide the prompting intervention, and it is uncertain whether implementation with usual nursing staff would be similarly effective given constraints of added cost and nursing time.

●In residents who are at high risk for falls due to urinary urgency, consider pharmacologic therapy with bladder relaxant agents for urge incontinence and overactive bladder.

●Beta-3 agonists (mirabegron and vibegron) do not have antimuscarinic side effects and can be safely used for those with cognitive impairment or susceptibility [126]. They can be costly but do not have the bothersome antimuscarinic effects of older medications.

●Because urge incontinence is associated with both cognitive and functional impairment in the SNF population, drug therapy must be combined with a toileting intervention such as prompted voiding. Individuals with severe cognitive impairment who are not able to cooperate with toileting interventions are not good candidates for drug therapy.

●Carefully selected individuals who are willing to undergo the risks, discomfort, and costs may benefit from further urologic, gynecologic, and/or urodynamic therapy. Examples of such patients may include female patients with severe pelvic prolapse or stress incontinence, male patients suspected of having obstruction, patients with recent pelvic surgery, and patients who have failed behavioral and/or drug therapy who are still bothered by their symptoms.

Acute urinary retention — Urinary retention is a common problem in the SNF. Unrecognized retention may be the etiology of pain, constipation, or agitation. It is especially common in male patients, due to prostate enlargement, but may be found in all adults in the setting of stroke or diabetes. It can also be triggered by anticholinergic medications such as antihistamines or tricyclic antidepressants. Many patients come from the acute-care hospital with an indwelling bladder catheter due to history of retention, especially after surgery, which needs follow-up in the SNF. An ultrasound bladder scanner, available in many SNFs, allows for quick and accurate diagnosis. In patients who have had an episode of significant urinary retention (ie, >400 mL), we typically place an indwelling catheter and leave it in place initially for 7 to 10 days to allow the bladder muscle to recover. A voiding trial is then initiated as soon as possible after that, when enough staffing is available for careful monitoring of urinary output and postvoid residual. The evaluation and management of acute urinary retention is presented elsewhere. (See "Acute urinary retention".)

Fecal incontinence — The most common cause of fecal incontinence in the SNF population is constipation and fecal impaction with leakage of loose stool around the impaction. Treatment should therefore address the constipation. Laxatives, antibiotics, and hyperosmolar supplements can also contribute to fecal incontinence. Fecal incontinence that is associated with a neurologic disorder or end-stage dementia is usually managed supportively in the SNF population.

Constipation — Constipation is common in SNF patients, with nearly 50 percent using laxatives regularly [127].

SNF patients recently discharged from an acute-care hospital often have constipation related to inactivity, impaired oral intake, medications such as opioids, and hospital-related environmental factors. These factors often resolve as functional status, diet, and the overall medical condition improves. Accordingly, bowel medications may need to be initiated on admission but reduced or eliminated later in the course of the SNF stay.

Constipation is generally defined as less than one bowel movement in a three-day period; hard stool with straining is also common regardless of frequency. Constipation can lead to anorexia, urinary retention, both urinary and fecal incontinence, social isolation, rectal prolapse, and fecal impaction, which in turn increase the risk of hospitalization. Rarely, severe constipation results in intestinal perforation. (See "Management of persistent unresponsive constipation in adults".)

Recognition of constipation is impeded in patients with cognitive deficits and impaired communication abilities. Constipation may also be missed because of suboptimal communication among nursing staff. The frequency and nature of bowel movements should be clearly and consistently documented in the nursing home record.

Many medications commonly used in SNF can cause constipation, including anticholinergics, opioids, iron, calcium, and NSAIDS. Treatment of medication induced constipation can contribute to polypharmacy if it is managed with laxatives rather than by eliminating or modifying the inciting medication(s).

Patients with constipation should be examined to exclude fecal impaction. Sometimes liquid stool is passed around a fecal impaction, resulting in fecal incontinence and delaying the diagnosis of constipation. Urinary retention or incontinence may also be a symptom of fecal impaction. Fecal impaction requires suppositories and/or manual disimpaction to avoid further complications as well as bowel management strategies to prevent recurrence.

A regular bulk-forming stool softener taken with adequate fluid is recommended; docusate has not been shown to be an effective stool softener or laxative and, despite its widespread use, is probably not the best choice. If there is no movement after two days, an osmotic agent should be administered (eg, polyethylene glycol). (See "Management of persistent unresponsive constipation in adults".)

Privacy, responsiveness, and flexibility around the timing of toileting are important factors in helping avoid constipation and incontinence. Regular attempts after breakfast to take advantage of the normal gastrocolic reflex are encouraged.

ADVANCE CARE PLANNING — 

Advance care planning is a process designed to elicit preferences for medical treatments and goals of care. Short-term patients as well as long-term SNF residents often have serious medical illnesses and life-limiting conditions, and cognitive impairment from reversible or permanent causes is frequent. Planning for future treatment by establishing and clearly documenting conversations and the advance care plan is essential in this population and should begin with identifying a surrogate decision maker and understanding goals of care before the individual is no longer able to participate.

SNFs in the United States, like other health care institutions receiving federal funding, are required by the Patient Self-Determination Act (PSDA) of 1990 to ask residents if they have an advance directive and, if they do not, whether they would be interested in information about advance care planning. Since implementation of the PSDA, the rate of completion of advance directives among SNF patients has risen to 55 percent [128]. Identifying a surrogate to serve as health care proxy when important medical decisions must be made is imperative since the majority of long-term SNF residents have some degree of dementia, and even cognitively intact older adult individuals are at risk of delirium should they become acutely ill. Because some SNF patients/residents are admitted to the SNF without a designated proxy or available family member, a guardian may need to become involved in advance care planning. The process for appointing a guardian may involve additional expense and time. (See "Advance care planning and advance directives".)

Conversations between the SNF resident and the health care proxy can help prioritize among the patient's goals of care (eg, life prolongation, maintenance of function, maximization of comfort) and allow the proxy, working with the clinician, to infer what kind of approach to treatment would be most appropriate [129].

Various interventions have been evaluated to increase use of advance directives in SNFs [130]. Short videos have been shown in some, but not all trials to help patients and families prioritize their goals of care and establish an advance care plan [131-133]. Many web-based resources are available to assist SNF residents, their families/loved ones, and SNF staff in discussing and executing advance directives [134-136]. A manuscript with an accompanying video provides a guide to conducting meetings with patients/residents and families focused on advance care planning [137].

Assessment of decision-making capacity is essential to determine if a health care proxy needs to be activated. Decision-making capacity is a clinical judgment and should not be confused with "competency," which is a legal determination by a court. This assessment is often performed with the input from the SNF care team, including clinicians, therapists, nurses, and social workers. Mental health clinicians may be asked to participate as well. Having decision-making capacity includes the ability to understand current medical issues and the ramifications of choosing or not choosing specific treatments. Facilities may require that the clinician meet specific documentation requirements to activate a health care proxy. (See "Legal aspects in palliative and end-of-life care in the United States", section on 'Decision-making capacity'.)

Do not resuscitate orders — Do-not-resuscitate (DNR) orders are the most common form of advance directive in the nursing home: 56 percent of residents have a DNR order, compared with only 18 percent with a living will [138]. Choosing whether to be designated DNR is especially important since, based on Centers for Medicare and Medicaid Services (CMS) rules, SNFs are required to initiate basic life support after a cardiac arrest unless a resident has a DNR order in place, although outcomes following cardiopulmonary arrest are poor in this population [139-143]. (See "Ethical issues in palliative care".)

Many SNFs now have automated external defibrillators for use when appropriate, but no data are available on their use or effectiveness in this setting. Residents and their families/surrogate decision makers should understand that a DNR order only refers to withholding cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest and that no other treatments will be withheld unless otherwise specified.

Physician Order Form for Life-Sustaining Treatment — Resident goals of care and treatment preferences should be honored across settings of care. Thus, information regarding preferences and relevant medical orders should travel from the SNF to the hospital and back. In practice, however, this information may be lost at the time of transfer [144]. Use of medical orders that are valid and recognizable across all sites of care such as the Physician Order Form for Life-Sustaining Treatment (POLST) is considered a best practice for patient-centered care [145]. Using the POLST as part of the advance care planning process has been shown to systematically provide more detailed information about patient treatment preferences [146]. Some states use different terminology for these orders, including Medical Orders for Life-Sustaining Treatment and Physician Orders for Scope of Treatment. POLST forms are an active medical order set and include preferences for code status, intensive care unit-level care and hospitalization, and may include other common treatment decisions, such as artificial nutrition or antibiotic use. Use of a POLST form is voluntary and a patient may choose to fill out part of a form (eg, code status and hospitalization preference only).

Hospitalization — In addition to specifying whether particular interventions such as CPR or intubation are desired, SNF patients and their surrogate decision makers may request to avoid hospitalization, opting for supportive treatment in the SNF. This can be entered as a do not hospitalize (DNH) order or be designated on a POLST form.

The likelihood of hospitalization is significantly increased in patients with dementia [147] and can be particularly burdensome [148]. Focusing on treatment within the SNF may be particularly reasonable in patients with advanced dementia for whom transfer to another location can be traumatic and unlikely to provide benefit. Orders to forgo hospitalization for those with advanced dementia are written for only a minority of such patients, with rates varying between states from 0.7 to 25.9 percent [149]. However, even in the case of a DNH preference, if comfort cannot be achieved in the SNF then a transfer to hospital may be appropriate. (See "Care of patients with advanced dementia", section on 'Hospitalization'.)

Discussion with residents and their families or other decision makers about the goals of care may lead to a DNH order or enrollment in hospice. The Interventions to Reduce Acute Care Transfers (INTERACT) program website has educational tools available for these discussions and a decision guide on this issue for SNF residents and their families/other decision makers.

Hospice and palliative care — Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients with serious medical illness and their families. Hospice care is palliative care provided near the end of life. Palliative care, however, does not have to be limited to end-of-life care and can be provided along with curative or life-prolonging treatments. Some palliative care practices do provide consults in the SNF setting; hospice providers may also offer nonhospice palliative care consultation. With the growth of telemedicine, there is an opportunity to provide palliative care consultation virtually in SNFs. Most SNFs, however, do not have palliative care consultation available [150].

One-quarter of all United States deaths take place in the SNF [151]. Moreover, among older adult decedents, 30 percent spent some time in a SNF in their last six months of life, even if they died in the hospital or at home; for decedents over age 85, the rate of antecedent SNF use is 40 percent [152]. Nonetheless, access to palliative care services has been limited. Further, in a large national study, only 42 percent of bereaved family members whose loved one died in a SNF reported the quality of care as excellent compared with 71 percent of family members whose loved one was home with hospice [153].

Hospice services are the predominant way that SNF patients receive formal end-of-life palliative care services, and hospice care is available in nearly all SNFs. Hospice care providers must coordinate with SNF staff and providers to support the patient. One study found that the quality of care of dying SNF patients improved with the addition of hospice, with the percent of families rating physical symptom control as good or excellent rising from 64 to 93 percent [154]. Hospice use in the SNF rose from 14 percent in 1999 to 33 percent in 2006 [155]. However, SNF patients/residents cannot receive Medicare Part A benefits for both postacute short-stay care and hospice care simultaneously. (See 'Financing of SNF care' above.)

Hospice care in the United States, including eligibility, is discussed in detail elsewhere. (See "Hospice: Philosophy of care and appropriate utilization in the United States", section on 'The United States Medicare hospice benefit'.)

PREVENTING UNNECESSARY HOSPITALIZATION — 

Acute hospitalization exposes patients to the risk of hospital-associated delirium, iatrogenic infections, and falls and increases medical care costs. Hospitalizations may be unnecessary or avoidable for many SNF patients/residents for one of several reasons, including:

●The patient's goals of care are not consistent with acute hospitalization

●The condition can be appropriately and safely treated in the SNF setting

●Appropriate preventive measures might have avoided the acute condition

Preventive interventions can decrease the risk of many conditions that account for hospitalizations in older adults [156]. These conditions include influenza, bacterial pneumonia, heart failure, dehydration, duodenal ulcer, urinary tract infection (UTI), skin ulcers and cellulitis, and chronic obstructive pulmonary disease and asthma.

Several strategies have been proposed to avoid inappropriate hospitalization:

●Early recognition of medical problems with proactive treatment may avoid later need for hospitalization. A study of 25 SNFs using such an approach found a 17 percent decrease in hospitalization rate [157].

●Medication reconciliation can ensure that no clinically important medications have been omitted when patients are transferred between settings. (See 'Prevention of adverse drug events' above.)

●Discussions and documentation of goals of care and treatment preferences, including timely referral to palliative care and hospice. An alert to clinicians identifying hospice-eligible nursing home residents led to an increase in patients enrolled in hospice and to a 40 percent decrease in subsequent acute care admissions [158].

●Centers for Medicare and Medicaid Services (CMS) demonstration projects involving 143 SNFs developed multiple approaches to prevent avoidable hospitalizations [159,160]. All of these approaches involved implementation of one or more components of the Interventions to Reduce Acute Care Transfers (INTERACT) program [12]. Sites that involved adding nurses and nurse practitioners into direct resident, including implementing the INTERACT program and evaluating acute changes in condition, were particularly successful [159,161].

●Vaccination programs for influenza, pneumococcal pneumonia, respiratory syncytial virus (RSV), and COVID-19.

The highest risk time for hospitalization of a SNF patient is following a recent hospitalization. Thus, many interventions are targeted at the higher risk period at the time of transfer into the SNF in order to prevent readmissions to the hospital. In response to the high rates of readmission from any setting back to the acute-care hospital within 30 days of discharge, Medicare now penalizes hospitals for such events [162]. Rates of rehospitalization are even higher for patients discharged to SNFs than for other patients discharged from hospitals, reaching 25 percent within 30 days [163], and it has been estimated that as many as 69 percent of the readmissions from such facilities are potentially (probably or definitely) avoidable with high-quality skilled care [164].

Rates of potentially avoidable hospitalizations are now included in the five-star Care Compare quality rating system, and SNFs also have financial incentives to reduce readmissions to the hospital. In addition, value-based reimbursement strategies, such as accountable care organizations and bundled payments, incentivize the reduction of unnecessary emergency department visits and hospitalizations. These incentives, added to the goal of honoring preferences of residents to avoid care transitions, are motivating SNFs to add programs and resources to support responsive, appropriate, high-quality care in place.

SUMMARY AND RECOMMENDATIONS

●Components of care

•Comprehensive geriatric assessment – Patients entering a skilled nursing facility (SNF) should undergo a comprehensive geriatric assessment (CGA). In SNFs in the United States, the Minimum Data Set (MDS) is a mandated tool for the comprehensive evaluation of residents within 14 days of admission to all facilities that receive federal funding as well as for quarterly reassessment for long-term residents. (See 'Comprehensive geriatric assessment' above and 'The Minimum Data Set' above.)

•Rehabilitation – Postacute patients are typically expected to make gains in function and therefore usually receive some combination of physical therapy, occupational therapy, or speech therapy. (See 'Rehabilitation' above.)

•Recognizing new medical issues and preparing for discharge – To achieve home discharge, SNF staff must deliver medical care for problems diagnosed in the acute-care hospital, facilitate rehabilitation, and remain alert for the occurrence of new problems. The interdisciplinary team must prepare the resident and caregivers for a safe transition to a home environment by identifying home supports the patient will need. (See 'Recognition of new medical issues' above and 'Anticipating needs after discharge' above.)

●Behavioral issues – Behavioral issues can be difficult challenges in the SNF setting and are often associated with moderate to advanced dementia. Delirium, however, requires assessing for and managing underlying medical conditions, including electrolyte imbalance, dehydration, pain, and infection. Although antipsychotic agents are considered chemical restraints and their use is carefully scrutinized in the SNF, psychotic symptoms and aggressive behaviors may need to be managed with psychotropic medications, typically atypical antipsychotic medications. (See 'Delirium' above and 'Behavioral issues associated with dementia' above.)

●Preventing falls – Falls are common in SNFs, and the risk of falls may be reduced by multidisciplinary interventions and by limiting medications that are associated with falls. (See 'Falls' above and "Falls: Prevention in nursing care facilities and the hospital setting".)

●Vaccinations – SNF staff and patients/residents should receive all age-appropriate vaccinations, including influenza, COVID-19, pneumococcus, herpes zoster, and tetanus-diphtheria (as indicated). (See 'Infections' above and "Standard immunizations for nonpregnant adults".)

●Outbreaks – In the event of an influenza outbreak, exposed patients should receive antiviral prophylaxis. Additional infection control measures should be instituted, such as limiting movement between affected and unaffected units of the SNF and closing affected units to new admissions. These issues are discussed separately. (See "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention" and "Infection control measures for prevention of seasonal influenza".)

●Pain management – Pain is common and often undertreated in the SNF setting. Many nonpharmacologic interventions as well as topical medications can be very helpful. Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided due to their toxicity. Patients/residents with cognitive impairment and pain should be treated with routine analgesics as they often will not request medication. Pain at the end of life poses unique challenges; transdermal and sublingual preparations of opioids can be particularly useful in end-of-life care. (See 'Pain' above and "Approach to the management of chronic non-cancer pain in adults" and "Approach to symptom assessment in palliative care", section on 'Pain'.)

●Nutrition – Unintentional weight loss is associated with increased mortality and requires evaluation for reversible causes, such as depression, oral or neurologic issues, or medication side effects. There is no evidence that percutaneous endoscopic gastrostomy tubes improve nutritional status or prolong life in the nursing home resident with advanced dementia. Oral nutritional supplements may be modestly helpful. (See 'Nutrition and hydration' above.)

●Pressure injury – Pressure injury management requires an interdisciplinary approach. Patients with pressure injuries often are nutritionally compromised and may require increased protein intake for wound healing. (See 'Pressure injury' above and "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

●Prevention of adverse drug events – Polypharmacy is very common in the SNF setting. Pharmacists and clinicians should regularly review medication lists, with recognition that indications for treatment change as patient/resident status changes. A collaborative, person-centered approach is critical to successful deprescribing and optimization of drug therapy. (See 'Prevention of adverse drug events' above and "Prevention of adverse drug events in hospitals" and "Deprescribing".)

●Advance care planning – Advance care planning is a process to understand goals of care and treatment preferences and is an important part of person-centered SNF care. In addition to addressing issues around resuscitation, residents should be given the option of addressing preferences for hospitalizations and other treatments. (See 'Advance care planning' above and "Advance care planning and advance directives".)

●Preventing unnecessary hospitalization – Changes in reimbursement and financial penalties are increasing pressure on SNFs to reduce potentially avoidable hospitalizations, 30-day readmissions, and emergency department visits. Multiple interventions are available to assist SNFs in achieving these goals. (See 'Preventing unnecessary hospitalization' above.)

ACKNOWLEDGMENTS — 

The UpToDate editorial staff acknowledges Mark Yurkofsky, MD, and Muriel Gillick, MD, who contributed to earlier versions of this topic review.