Skilled Nursing Facility Care At Home

Launched by BRIGHAM AND WOMEN'S HOSPITAL · May 11, 2024

Keywords

ClinConnect Summary

This clinical trial, called "Skilled Nursing Facility Care at Home," is studying whether patients can receive skilled nursing care at home instead of going to a skilled nursing facility after being hospitalized. This approach uses a team of healthcare professionals who will support patients in their own homes with the help of technology. Patients who are eligible for the trial are typically those over 18 years old who need rehabilitation care after hospitalization but can live in their own homes. They must also have been living independently before being hospitalized and live within 10 miles of a participating hospital.

Participants in the study will be randomly assigned to either receive care at home or continue their recovery in a traditional skilled nursing facility. The goal is to find out which option is better for their recovery. It’s important to note that not everyone will qualify; for example, people who need more assistance than one caregiver can provide, or those living in unsafe conditions, cannot participate. If you or a loved one are interested in this study, it could be a great opportunity to explore a more comfortable recovery option at home.

Gender

ALL

Eligibility criteria

• 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