WE ServE Community-based Skilled NURSING Facilities

Hospitals have become reliant on skilled nursing facilities to accept sicker, high risk patients in their effort to reduce their own lengths of stay. Unfortunately, research shows this tactic doesn’t work and nearly 25% of these vulnerable patients return to the hospital within 2-4 weeks of discharge. 

A big part of the problem is the increased complexity of these patients, most of whom have multiple chronic conditions. In addition, hospitals tend to treat what the patient came in for and other chronic conditions may or may not have been treated or stabilized.  

Skilled Nursing Facilities also lack the robust support of specialists enjoyed by hospitals and long term acute care facilities to mange such patients. Moreover, the use of tools like function-focus clinical care pathways to manage complex patients with multiple chronic conditions is not uniformly practiced.  

CHFCare providers are experts at practicing Cardiopulmonary Medicine in skilled nursing facilities. We implement our targeted programs to manage patients with different needs including newly discharged patients, intermediate rehabilitation patients, and long term residents. Our solutions are personalized and blend with the existing care plan. We are focused on quality care delivery and our approach has been demonstrated to improve SNF readmission and mortality rankings as well as overall star-ratings.


CHFCare uses a systematic approach to treating all patients which ensures every patient gets the care they need and assures delivery of quality care. 

CHFCare assigns the same care delivery team (CDT) of providers to each skilled facility. This allows a true partnership to form and the CHFCare CDT gets to know facility residents very well and develops close working relationship with the administrative and clinical staff.  

CHFCare provides 24/7 patient coverage and support to nursing and clinical staff.  We also provide training, in-service,  and continuing education when requested. Nurses at all levels are encouraged to be proactive and call the CHFCare CDT with any questions or concerns. We don’t mind false alarms at all because it means the early warning system is working.  


Many of the 20-25% 30-day hospital re-admissions are unrelated to the initial problem and represent a worsening of one or more chronic conditions. These readmissions are very disruptive to residents’ quality of life and can often be prevented with diligent monitoring and regular assessment by the CHFCare team. 

Our Transitional Care Program (TCP) for SNFs mirrors our Transitional Care Clinic set up to help non-SNF vulnerable patients discharge into the community. Both our transitional programs were designed to smooth the return to normal life after an acute disruption by hospitalization. The key is using a consistent process for assuring stability of the patient’s multiple chronic conditions so that none exacerbate others leading to readmission. CHFCare clinical pathways ensure that evidence-based treatments are re-instituted for each condition. The program’s overarching goal is to keep patients moving forward in their recovery process and return to their normal. 


As many as 3 out of 4 people aged 65 and older have two or more chronic conditions that negatively impact their activities of daily living. This is why our experience practicing cardiopulmonary medicine in long-term facilities is advantageous. A complaint of difficulty breathing can be caused by many conditions of the heart, lungs, kidneys, or even something like anemia. 

Our broad experience simultaneously managing multiple chronic conditions means vulnerable and debilitated residents do not have to run back and forth to multiple specialists risking infection and other harm. CHFCare brings a high level of expertise right to the patient’s bedside.  Our programs are designed to keep patients safely at their facility while providing best care anywhere. Our technology-savvy practitioners can perform many point of care diagnostic heart tests right in the residents room when ordered.