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