About this trial
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.
Eligibility criteria
Qualifiers
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
Disqualifiers
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
Trial design
Treatments tested in this trial
- Sub-Acute Rehab at Home
Treatment groups
Sponsors and collaborators
University of Massachusetts, Worcester
Lead sponsor
Baystate Health
Collaborator
UMass Memorial Health
Collaborator
Massachusetts Executive Office of Health and Human Services (EOHHS)
Collaborator