Skilled Nursing Facility at Home Trial
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: Sub-Acute Rehab at Home.
- Who it may be relevant to
- Registry conditions: Skilled Nursing Facility, Rehabilitation, Home Based Care. Basic parameters: from 18 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- United States
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
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Overview
Skilled Nursing Facility at Home is a multicenter randomized control trial that aims to evaluate a home-based model of providing post-acute care (PAC). We will enroll 650 hospitalized patients who require rehabilitation and/or skilled-nursing support upon discharge and randomly assign them to an intervention (home-based PAC) or control arm (facility-based PAC). Our design includes two different health systems in Massachusetts: Baystate Health and UMass Memorial Health. We will perform 1:1 randomization between the intervention and control arm using a permuted block design, with stratification by clinical site and payor group. The primary outcome of the trial will be the difference in hospital readmission and mortality rates from the time of enrollment to 30 days after enrollment. Secondary clinical, functional, and cost outcomes include length of stay in PAC, difference in health-related quality of life (HRQoL), and healthcare cost and utilization.
Interventions
- Other Sub-Acute Rehab at Home
Patients randomized to the intervention group will receive skilled nursing and rehabilitative care at home upon discharge from the hospital, or when eligible for skilled-nursing facility care when requiring a step up in services at home. Home care will be delivered and overseen by a multidisciplinary clinical team, which will develop individualized care plans based on diagnosis, specific rehabilitation objectives, and broader goals of care.
Primary outcome measures
- 30-Day Readmission and Mortality [Time frame: From time of enrollment to 30 days after enrollment]
Secondary outcome measures (6)
- 90- and 180- day Readmission and Mortality [Time frame: From time of enrollment, up to 6 months post-enrollment]
- Days Alive [Time frame: From time of enrollment, up to 6 months post-enrollment]
- Activities of Daily Living [Time frame: From time of enrollment, up to 6 months post-enrollment]
- Healthcare Costs [Time frame: From time of enrollment, up to 6 months post-enrollment]
- Mortality rate [Time frame: From time of enrollment to 6 months post-enrollment]
- Length of stay [Time frame: From time of enrollment, up to 6 months post-enrollment]
Eligibility criteria
Inclusion criteria
- Age 18 or older
- Admitted to an inpatient unit OR receiving home health and requiring an escalation to skilled-nursing facility care
- Require post-acute care in a skilled nursing facility based on the clinical inpatient team's assessment (or, if the participant is coming from home, based on the home health team's assessment)
- Pass the home readiness assessment
- Reside within Greater Worcester or Greater Springfield
Exclusion criteria
- Inability to return to a home residence where care can be provided
- Inability for patient or their proxy to provide informed consent for the study
- Requires long-term care
- Requires palliative or hospice care
- On active chemotherapy
- Post-transplant surgery
- Requires hemodialysis
- Requires radiation therapy
- Requires two-person assist or mechanical lift
- Expresses unwillingness to be randomized to SNF OR SNF at Home care
- Considered clinically inappropriate by SNF at Home clinical team
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Single blind
- Primary purpose
- Health services research
Study locations
United States · 2 centers
- Baystate Medical Center — Springfield
- UMass Memorial Medical Center — Worcester
Identifiers
NCT: NCT06547645 · STUDY00001862