AHA Skilled Nursing Facility Heart Failure

The overarching goals of the American Heart Association Skilled Nursing Facility Heart Failure certification is focused on standardizing heart failure patient care and is designed to evaluate each skilled nursing facility against a professional set of criteria based on demonstrated adherence to key standards and a rigorous review process. 

The program goals:  

  • Ensure evidence-based heart failure guidelines are driving decision making at all levels of care represented in the skilled nursing facility. 
  •  Provide guidance and leadership on measurably improving care coordination and communication between and among care providers. 
  • Demonstrate that high levels of compliance for one or more of these entities through certification or recognition results in measurable improvements in clinical quality of care and cost effectiveness. Benefits for Patients.
  •  Provide patients with access to centers focused on treating heart failure and its comorbidities. 
  • Provide patients with confidence that the centers can provide the most effective treatment strategies based on current translational, evidence-based research in heart failure. 
  • Provide patients with assurance that the center has been vetted and is recognized by the American Heart Association, based on professional evaluation


Benefits for Patients: 

  • Provide patients with access to centers focused on treating heart failure and its comorbidities 
  • Provide patients with confidence that the centers can provide the most effective heart failure treatment strategies 
  • Provide patients with assurance that the center has been vetted and is recognized by the American Heart Association, based on professional evaluation criteria designed by heart failure expert
  • Heart Failure Certified staff who have monthly HF focused continuing education
  • Increased  education on managing their heart failure - from  understanding it, better diets, Medication management  & Smoking Cessation resources.  
  • Increased Care coordination with Acute Care team, Cardiac Specialist, Laboratory, & Post Acute Discharge Team

Benefits for Acute Partners: 

  • Improves care coordination and communication between the Hospital and SNF(s), in turn enhancing the continuum of care for the patient for improved outcomes 
  • Gives the hospital assurance that the patient will have strong continuity of care 
  • The hospital can have confidence that the SNF(s) have been highly vetted by AHA experts
  • Increased Care coordination with Acute Care team, Cardiac Specialist, Laboratory, & Post Acute Discharge Team
  • Improved readmission rates due to unnecessary readmissions and possible savings.
  • Enhanced continuum of care for the patient through improved care coordination and communication between the Hospital and Facility. 
  • Opportunity to demonstrate quality of care through patient outcomes. 
  • Confidence of certification built on the Association's science and guidelines.

What does it mean to be AHA Heart Failure Program Certified? 

The Heart Failure (HF) program is managed under a structured oversight model that includes a designated Program Champion and an Interprofessional Committee (IPC). This committee is composed of representatives from various disciplines involved in the care of heart failure patients and convenes quarterly to support program development, implementation, and ongoing quality improvement. 

Clinical Assessments

  • Nursing Assessment: within 4 hours of admission
  • Provider Assessment: within 24 hours (physician or APP)
  • Rehabilitation Assessment: by the next business day
  • Daily Nursing HF Assessments: continue throughout stay

Ongoing HF Monitoring Includes:

  • Regular checks of vital signs, weight, and fluid balance
  • Screening for HF decompensation
  • Nutritional guidance (sodium/fluid restrictions)
  • Self-care and medication management education
  • Therapy evaluations as needed
  • Support for palliative/hospice care
  • Psychosocial screening (e.g., depression)

Education & Support 

All staff participate in the Cardiac Management Skilled Nursing and Rehabilitation Training Curriculum.

  • Ongoing heart failure education is provided through the Genesis Heart Failure Education Calendar.
  • Annual and new employee compliance is tracked via the center’s staff education roster.


Patient & Caregiver Education & Support

Education starts at admission and continues throughout the patient’s stay, focusing on:

  • Recognizing signs and symptoms of worsening heart failure (e.g., Heart Failure Zones, Symptom Tracker)
  • Monitoring daily weights
  • Sodium and potassium dietary guidelines
  • Medication management and addressing access barriers (e.g., transportation)
  • Encouraging physical activity and healthy lifestyle habits (e.g., diet, immunizations, smoking cessation)
  • Promoting self-care and understanding care goals
  • Involving patients and caregivers in developing the care plan
  • Using an HF Education Order Template to assess learning needs, preferences, and caregiver readiness

Before Discharge from Post-Acute Facility

Reconfirm and document all of the above, and prepare the patient/caregiver with necessary follow-up instructions and support.

Pre-Discharge Education Includes:

  • Expected care needs after discharge
  • Medication access and management (prescription and over-the-counter)
  • Who to contact with questions
  • Scheduling and confirming follow-up appointments (e.g., PCP, outpatient therapy)
  • When to call a healthcare provider or 9-1-1

Simplified Care Coordination Across Settings

Our HF program ensures seamless coordination of care across three key areas:

  • From acute care to post-acute care
  • During the post-acute stay
  • From post-acute care to discharge destination

Post-Discharge Follow-Up (Within 48–72 Hours)

  • Confirm a follow-up appointment with PCP/APP within 7–10 days
  • Review medication and dietary adherence
  • Check weight monitoring compliance
  • Assess for worsening HF symptoms
  • Address patient or caregiver concern

Performance Improvement & Accountability 

  • The program tracks and improves HF care via QAPI or the HF Interprofessional Committee
  • Data Collection: At least 3 of 6 HF quality measures and all HF outcome metrics
  • Review Frequency: Monthly tracking, quarterly reporting
  • Actions Taken:
    • Identify gaps
    • Implement education plans
    • Measure effectiveness
    • Communicate updates to frontline staff