Skilled Nursing Facility at Home: A Pilot

NCT ID: NCT04048590

Last Updated: 2019-12-23

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

10 participants

Study Classification

INTERVENTIONAL

Study Start Date

2019-08-05

Study Completion Date

2019-12-19

Brief Summary

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We seek to pilot a randomized controlled evaluation of skilled nursing facility care at home. We plan to enroll patients who would normally be sent to a skilled nursing facility following following hospitalization. As a substitute for a skilled nursing facility, we will deploy a technology-enabled team to the home to care for patients.

Detailed Description

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Post-acute care (PAC) encompasses the wide range of rehabilitative services used to restore a patient's maximal functional status following discharge from an acute hospitalization with the goal of restoring healthful aging. Approximately 40% of all hospitalized Medicare beneficiaries utilize PAC, accounting for 20% of all Medicare expenditures. PAC is a fast-growing segment of Medicare, and for some conditions, Medicare spending on PAC nearly equals that of the initial hospitalization, with skilled nursing facility (SNF) PAC accounting for most of these trends. The quality of SNF PAC is suspect, with substantial regional variation, insufficient physical therapy delivery, high readmission rates, poor attention to whole-person care, and poor patient experience. Given these concerns, some experts have called for national improvement.

The investigators propose a home-based PAC model that substitutes for treatment in a traditional SNF PAC facility. We believe that rehabilitation following hospitalization in one's home has several benefits: support tailored to one's actual living circumstances, an environment that encourages earlier mobilization, support of and interaction with family and caregivers, and psychosocial benefits of being at home. To promote aging in place, the investigators plan to deploy an innovative and tailored set of SNF PAC services delivered in a patient's home that would allow for discharge from the hospital directly to home, despite the need for more intensive rehabilitative care not currently found in the home setting. The investigators plan to combine a high-touch and high-tech approach that combines novel uses of personnel practicing at the very top of their license (certified nursing assistants, nurses, home health aides) with novel uses of technology (virtual physical therapy with three-dimensional camera feedback, continuous monitoring, and video visits).

Conditions

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Skilled Nursing Facilities Rehabilitation

Keywords

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Skilled Nursing Facilities Home-based care Rehabilitation

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

OTHER

Blinding Strategy

NONE

Study Groups

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Control

Control subjects will receive care at a skilled nursing facility.

Group Type NO_INTERVENTION

No interventions assigned to this group

Intervention

Intervention subjects will go home from the hospital and receive care from a specialized care team.

Group Type ACTIVE_COMPARATOR

Skilled Nursing Facility at Home

Intervention Type OTHER

We plan to deploy an innovative and tailored set of rehabilitation services delivered in a patient's home that would allow for discharge from the hospital directly to home, despite the need for more intensive rehabilitative care not currently found in the home setting. We plan to combine a high-touch and high-tech approach that combines novel uses of personnel practicing at the very top of their license with novel uses of technology.

Interventions

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Skilled Nursing Facility at Home

We plan to deploy an innovative and tailored set of rehabilitation services delivered in a patient's home that would allow for discharge from the hospital directly to home, despite the need for more intensive rehabilitative care not currently found in the home setting. We plan to combine a high-touch and high-tech approach that combines novel uses of personnel practicing at the very top of their license with novel uses of technology.

Intervention Type OTHER

Other Intervention Names

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Rehab at Home

Eligibility Criteria

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Inclusion Criteria

* \>=18 years old
* Requires skilled nursing facility care following hospitalization, as determined by inpatient team
* Lives within 10 miles of Brigham and Women's Hospital (BWH) or Brigham and Women's Faulkner Hospital (BWFH)
* Has capacity to consent
* Likely to return to community dwelling status
* Patient on medical service

* Pending low volume, we reserve ability to phase in patients on surgical services, including orthopedic trauma

Exclusion Criteria

* Social

* Undomiciled
* No working heat (October-April), no working air conditioning if forecast \> 80°F (June-September), or no running water
* In police custody
* Resides in facility that does not allow advanced on-site medical care
* Domestic violence screen positive
* Clinical

* Requires care of new ostomy or teaching ostomy care associated with complication
* Requires frequent suctioning, tracheostomy, and/or ventilator needs
* Requires significant durable medical equipment not already in place at home (e.g., Hoyer lift)
* Home unable to accommodate patient in current state as determined by the SNF-at-Home Checklist for Home
* Acute delirium
* End stage renal disease on hemodialysis
* 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 multiple transfers back and forth to hospital for specialty medical care
* Home SNF census is full
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Spire Health, Inc.

UNKNOWN

Sponsor Role collaborator

Reflexion Health, Inc.

INDUSTRY

Sponsor Role collaborator

Brigham and Women's Hospital

OTHER

Sponsor Role lead

Responsible Party

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David Levine

Principal Investigator

Responsibility Role PRINCIPAL_INVESTIGATOR

Principal Investigators

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David Levine, MD, MPH, MA

Role: PRINCIPAL_INVESTIGATOR

Brigham and Women's Hospital

Locations

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Brigham and Women's Hospital

Boston, Massachusetts, United States

Site Status

Brigham and Women's Faulkner Hospital

Boston, Massachusetts, United States

Site Status

Countries

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United States

References

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Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing. 2006 Jan;35(1):53-60. doi: 10.1093/ageing/afi206. Epub 2005 Oct 20.

Reference Type BACKGROUND
PMID: 16239239 (View on PubMed)

David S, Sheikh F, Mahajan D, Greenough W, Bellantoni M. Whom Do We Serve? Describing the Target Population for Post-acute and Long-term Care, Focusing on Nursing Facility Settings, in the Era of Population Health in the United States. J Am Med Dir Assoc. 2016 Jul 1;17(7):574-80. doi: 10.1016/j.jamda.2016.05.004. No abstract available.

Reference Type BACKGROUND
PMID: 27346649 (View on PubMed)

Mechanic R. Post-acute care--the next frontier for controlling Medicare spending. N Engl J Med. 2014 Feb 20;370(8):692-4. doi: 10.1056/NEJMp1315607. No abstract available.

Reference Type BACKGROUND
PMID: 24552315 (View on PubMed)

Chandra A, Dalton MA, Holmes J. Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings. Health Aff (Millwood). 2013 May;32(5):864-72. doi: 10.1377/hlthaff.2012.1262.

Reference Type BACKGROUND
PMID: 23650319 (View on PubMed)

Levine DM, Cueva MA, Shi S, Limaj I, Wambolt B, Grabowski DC, Schnipper JL, Pu CT. Skilled Nursing Facility Care at Home for Adults Discharged From the Hospital: A Pilot Randomized Controlled Trial. J Appl Gerontol. 2022 Jun;41(6):1585-1594. doi: 10.1177/07334648221077092. Epub 2022 Mar 10.

Reference Type DERIVED
PMID: 35266835 (View on PubMed)

Other Identifiers

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2019P001231

Identifier Type: -

Identifier Source: org_study_id