Skilled Nursing Facility at Home Trial

Last updated: March 9, 2026
Sponsor: University of Massachusetts, Worcester
Overall Status: Active - Recruiting

Phase

N/A

Condition

N/A

Treatment

Sub-Acute Rehab at Home

Clinical Study ID

NCT06547645
STUDY00001862
  • Ages > 18
  • All Genders

Study Summary

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.

Eligibility Criteria

Inclusion

Inclusion Criteria:

  • Age 18 or older

  • Admitted to an inpatient unit OR receiving home health and requiring an escalationto skilled-nursing facility care

  • Require post-acute care in a skilled nursing facility based on the clinicalinpatient team's assessment (or, if the participant is coming from home, based onthe home health team's assessment)

  • Pass the home readiness assessment

  • Reside within Greater Worcester or Greater Springfield

Exclusion

Exclusion Criteria:

  • Inability to return to a home residence where care can be provided

  • Inability for patient or their proxy to provide informed consent for the study

  • Requires long-term care

  • Requires palliative or hospice care

  • On active chemotherapy

  • Post-transplant surgery

  • Requires hemodialysis

  • Requires radiation therapy

  • Requires two-person assist or mechanical lift

  • Expresses unwillingness to be randomized to SNF OR SNF at Home care

  • Considered clinically inappropriate by SNF at Home clinical team

Study Design

Total Participants: 650
Treatment Group(s): 1
Primary Treatment: Sub-Acute Rehab at Home
Phase:
Study Start date:
August 26, 2024
Estimated Completion Date:
May 31, 2027

Connect with a study center

  • Baystate Medical Center

    Springfield, Massachusetts 01199
    United States

    Active - Recruiting

  • UMass Memorial Medical Center

    Worcester, Massachusetts 02446
    United States

    Active - Recruiting

  • Baystate Medical Center

    Springfield 4951788, Massachusetts 6254926 01199
    United States

    Site Not Available

  • UMass Memorial Medical Center

    Worcester 4956184, Massachusetts 6254926 02446
    United States

    Site Not Available

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