Pilot study finds promise in skilled nursing facility care at home
LONDON: Randomized pilot study testing the feasibility of rehabilitation at home found trends toward lower cost, greater functional status improvement and better patient experience
After a hospital stay, about 40 percent of patients will require follow-up care, and about half of these patients will be discharged to a skilled nursing facility (SNF). But the quality and safety of care that patients receive at SNFs are variable, the cost of care is high, and facilities may have limited admission capacity — issues that have been exacerbated by the COVID-19 pandemic. A pilot study led by a team at Brigham and Women’s Hospital investigated whether the cost of care and, secondarily, the quality, safety and experience of patients could be improved by shifting the site of care to the patient’s home. The team found signals toward lower cost of care, greater functional status improvement and better patient experience, laying the groundwork for larger scale studies.
“We are making a lot of progress in delivering advanced care at home, and SNF-level care is an example of what could come in the future,” said corresponding author David Levine, MD, MPH, MA, of the Division of General Internal Medicine and Primary Care at the Brigham. “My hope for the future is that this will become an option for rehabilitation for all patients who have been discharged once we conduct further studies and better understand the model’s limits.”
At a traditional SNF, care includes physical therapy, nursing care, assistance with functional limitations, medications, and semi-private room and board. Levine and colleagues designed a “rehabilitation-at-home” (RAH) care model to provide comparable services for patients discharged to home. In 2019, the team performed a pilot trial in which 10 participants were randomly assigned to RAH (intervention) or traditional SNF (control) care at a skilled nursing facility. Patients randomized to RAH were visited by a certified nurse assistant (CNA), a geriatric medicine attending physician and a physical therapist at home. The CNA visited daily and a nurse was available as-needed for virtual or in-person consultations. RAH also leveraged technology, including an automatic medication dispenser, a virtual therapy avatar that guided patients through daily physical therapy sessions, and remote monitoring of the patient’s biometrics, including heart rate, sleep, respiration and more.
Patients were generally in their 80s and were chronically ill and frail, with diagnoses including fracture, heart failure, pneumonia, and other infections.
The median cost of care for patients receiving RAH was $8,404 compared to $9,215 for the control group. The team also saw other signals of improvement, including improved patient experiences and an increase in activities of daily living, such as personal hygiene, toileting and feeding oneself.
The authors caution that, given the pilot study’s small sample size of 10 patients, there were differences between the RAH and control groups that they could not adjust for. The study also enrolled participants from only two sites — Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital — and may not be generalizable more broadly. The authors note that many patients who were approached declined to participate and that lessons learned from the pilot may help them to address recruitment challenges in the future.
“The ability for a patient to rehabilitate in the comfort of their own home can contribute to their recovery in many ways,” said Levine. “We know from previous work that patients who receive care at home have reduced anxiety levels and increased movement. Our study fits that pattern and lays an important foundation for a much-needed, larger randomized, controlled trial.”
