Skilled Nursing Facility Care At Home

Eligibility 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)
• * 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