Skilled Nursing Facility Care at Home

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