NCT06547645 · University of Massachusetts, Worcester
Skilled Nursing Facility at Home Trial
What this study is about
Skilled Nursing Facility at Home is a conducted at multiple hospitals randomly assigned control trial that aims to evaluate a home-based model of providing post-acute care (PAC).
View original scientific description
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.
Interventions
OTHER
Sub-Acute Rehab at Home
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.
Primary outcome measures
30-Day Readmission and Mortality
Time frame: From time of enrollment to 30 days after enrollment
Hospital readmission rates and mortality rates between the intervention and control groups in the first 30 days after enrollment
Who can participate
This study lists these criteria on ClinicalTrials.gov. A study coordinator reviews eligibility during screening — this page does not determine whether you qualify.
Inclusion criteria
- Age 18 or older
- Admitted to an inpatient unit OR receiving home health and requiring an escalation to skilled-nursing facility care
- Require post-acute care in a skilled nursing facility based on the clinical inpatient team's assessment (or, if the participant is coming from home, based on the home health team's assessment)
- Pass the home readiness assessment
- Reside within Greater Worcester or Greater Springfield
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
Where
- Springfield, Massachusetts
- Worcester, Massachusetts
Collaborators
Baystate Health, UMass Memorial Health, Massachusetts Executive Office of Health and Human Services (EOHHS)
Related conditions & keywords
Frequently asked questions
What is a clinical trial?
A clinical trial is a research study that tests new medical treatments, drugs, devices, or procedures to determine their safety and effectiveness. Trials are carefully designed and monitored to protect participants while advancing medical knowledge.
Is it safe to participate?
Clinical trials follow strict safety guidelines and ethical standards. Trials must be reviewed and approved, and participants are closely monitored by medical professionals throughout the study. You can withdraw at any time if you choose.
Will I be compensated?
Many clinical trials offer compensation for your time, travel expenses, and inconvenience. The specific compensation varies by study and will be discussed during the screening process. All study-related medical care is typically provided at no cost to participants.
Will I receive a placebo instead of treatment?
When effective treatment exists, participants typically receive either the standard treatment plus the study intervention, or the standard treatment plus placebo. You would not be denied effective care. Placebos are primarily used when no proven treatment is available, or in addition to standard care. Your trial consent form will clearly explain what treatments you may receive.
Can I leave a trial if I change my mind?
Absolutely. Participation in clinical trials is completely voluntary. You have the right to withdraw from the study at any time, for any reason, without penalty or loss of benefits to which you are otherwise entitled.
How long does a clinical trial last?
Trial duration varies widely depending on the study design and purpose. Some trials last just a few weeks, while others may continue for months or years. The study coordinator will provide specific timeline information during your screening call.
Data: ClinicalTrials.gov · synced Mar 11, 2026 · Source of record for eligibility and locations