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NCT Number: NCT06547645

Skilled Nursing Facility at Home 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.

Recruiting

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Key information

Conditions

Skilled Nursing Facility Home Based Care Rehabilitation

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Baystate Medical Center, Springfield, Massachusetts, United States

Loading trial locations.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

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

Treatment and study plan

Sub-Acute Rehab at Home

Other

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.

Other names: SNF at Home

Primary outcomes

  1. 30-Day Readmission and Mortality

    Time frame: From time of enrollment to 30 days after enrollment

    Hospital readmission rates and mortality rates between the intervention and control groups in the first 30 days after enrollment

Secondary outcomes

  1. 90- and 180- day Readmission and Mortality

    Time frame: From time of enrollment, up to 6 months post-enrollment

    Hospital readmission rates and mortality rates between the intervention and control groups in the 90- and 180- days after enrollment

  2. Days Alive

    Time frame: From time of enrollment, up to 6 months post-enrollment

    Starting with the day of randomization, the total number of days alive outside of the hospital during the study period.

  3. Activities of Daily Living

    Time frame: From time of enrollment, up to 6 months post-enrollment

    Compare the improvement in ability to perform activities of daily living between the intervention and control groups from time of enrollment to 30, 90 and 180-days after enrollment.

  4. Healthcare Costs

    Time frame: From time of enrollment, up to 6 months post-enrollment

    Compare healthcare cost incurred and healthcare utilization between the intervention and control group during the PAC episode as well as from time of enrollment to the end of the PAC episode.

  5. Mortality rate

    Time frame: From time of enrollment to 6 months post-enrollment

    Compare mortality rates during the study period between the intervention and control groups.

  6. Length of stay

    Time frame: From time of enrollment, up to 6 months post-enrollment

    Compare length-of-stay (number of days) that study participants receive post-acute, SNF-level care during the index PAC episode between the intervention and control groups

Study contacts

Contact information is provided by the study sponsor or research team.

Study Team

CONTACT

[email protected]

508-523-1284

Sponsors and collaborators

Lead sponsor

University of Massachusetts, Worcester

Other

Collaborators

  • Baystate Health
  • Massachusetts Executive Office of Health and Human Services (EOHHS)
  • UMass Memorial Health

Registry information

Important dates

Study start
2024
Primary completion
2026
Study completion
2027
First posted
Aug 9, 2024
Registry last updated
Mar 11, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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