Skilled Nursing Facility Care at Home

Running, not enrolling · Not applicable

Conditions studied: Skilled Nursing Facility, Rehabilitation

In brief

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.

Key facts

Study ID

NCT06416670

Run by

Brigham and Women's Hospital

People needed

300

Starts

2024-06-03

Expected to finish

2026-09-01

Last updated by the study team

2026-07-20

Who can join

Age: 18 and older. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• >=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)

You may not qualify if…

• 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

Where it is running

• Massachusetts General Hospital — Boston, Massachusetts, United States
• Boston Medical Center — Boston, Massachusetts, United States
• Brigham and Women's Hospital — Boston, Massachusetts, United States
• Brigham and Women's Faulkner Hospital — Boston, Massachusetts, United States
• Cambridge Health Alliance — Cambridge, Massachusetts, United States

Full record on ClinicalTrials.gov

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