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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE
Enrollment
650
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.
Baystate Medical Center
Springfield, Massachusetts, United States
RECRUITINGUMass Memorial Medical Center
Worcester, Massachusetts, United States
RECRUITING30-Day Readmission and Mortality
Hospital readmission rates and mortality rates between the intervention and control groups in the first 30 days after enrollment
Time frame: From time of enrollment to 30 days after enrollment
90- and 180- day Readmission and Mortality
Hospital readmission rates and mortality rates between the intervention and control groups in the 90- and 180- days after enrollment
Time frame: From time of enrollment, up to 6 months post-enrollment
Days Alive
Starting with the day of randomization, the total number of days alive outside of the hospital during the study period.
Time frame: From time of enrollment, up to 6 months post-enrollment
Activities of Daily Living
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.
Time frame: From time of enrollment, up to 6 months post-enrollment
Healthcare Costs
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.
Time frame: From time of enrollment, up to 6 months post-enrollment
Mortality rate
Compare mortality rates during the study period between the intervention and control groups.
Time frame: From time of enrollment to 6 months post-enrollment
Length of stay
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
Time frame: From time of enrollment, up to 6 months post-enrollment
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