Skilled Nursing Facility Care at Home

Mass General Brigham

Status

Active, not recruiting

Conditions

Rehabilitation

Skilled Nursing Facility

Treatments

Other: Skilled nursing facility care at home

Study type

Interventional

Funder types

Other

Identifiers

NCT06416670

2024P000266

Details and patient eligibility

About

We will perform a parallel-group multicenter patient-level randomized controlled evaluation of skilled nursing facility care at home. Patients typically referred to a skilled nursing facility following hospitalization will be eligible for enrollment. Instead of admission to a skilled nursing facility, participants will receive care from a technology-enabled team in their own homes or will be allocated to receive care in a traditional skilled nursing facility setting.

Enrollment

300 estimated patients

Sex

All

Ages

18+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

>=18 years old
Requires SNF PAC care following hospitalization, as determined by the inpatient team (requires documented rehabilitative therapy recommendation)
Community-dwelling before hospitalization
Likely to return to community-dwelling status following short-term rehabilitation as determined by RAH liaison
Lives within 10 miles of any study site hospital (or per specified catchment)
Surgical trauma and elective patients (weight bearing as tolerated and transfer with no more than one-person assist)
Neurology patients - Stroke (needs acute rehabilitation, but insurance will not cover, so bound for SNF. Does not meet acute rehabilitation criteria and does not need long-term placement)

Exclusion criteria

Environmental
- Undomiciled
- No working heat (October-April), no working air conditioning if forecast > 80°F, or no running water
- In police custody
- Resides in a facility that does not allow advanced on-site care
- Domestic violence screen positive
- Weapons that cannot be appropriately secured
- Difficulty accessing the bathroom (unless there is space for a bedside commode where the patient sleeps or if the patient is entirely dependent on toileting)
- Home has insufficient accessible space to sleep, eat, and perform rehabilitative therapy
- Home lacks sufficient kitchen facilities to either cook or heat meals
- Patient, or patient's family caregiver, unable to communicate via telephone
- Patient, or patient's family caregiver, lacks consistent access to a telephone
Clinical
- Requires more than one assist (unless the family can provide additional 24/7 assistance)
- Requires care of new ostomy or teaching ostomy care
- Requires frequent suctioning, tracheostomy, and ventilator needs
- Requires total parenteral nutrition
- Requires nasogastric tube feeds
- Requires durable medical equipment not already in place at home and excluded below
- Requires daily subcutaneous injection unless patient or family caregiver is teachable and able to administer daily
- Acute delirium noted by RAH liaison requiring more than one caregiver
- Active psychiatric diagnosis without an adequate treatment plan
- On methadone requiring daily pickup of medication
- Requires administration of intravenous controlled substances
- Requires administration of specialty medications not already in place at home
- Requires transfusion of blood products
- Requires three times weekly or more transfers back and forth to obtain specialty medical care
- Requires hemodialysis
- Orthopedic trauma and elective patients
- Traumatic brain injury
- Wound or appliance care that requires daily nursing care
- For spine trauma: neurologic deficits requiring more than one assist
Neurology patients
- PRESS score (for ischemic stroke; use PRESS app): no return to pre-stroke diet > 50%
- FUNC score (for primary intracerebral hemorrhage only): <75% probability of functional independence at 90 days
- ASTRAL score (for ischemic stroke only and patients with pre-stroke independence [Modified Rankin Scale 0-2]): <75% probability of a 90-day poor functional outcome (Modified Rankin Scale result of 3-6)
RAH census is full