We will perform a parallel-group multicenter patient-level randomized controlled evaluation of skilled nursing facility care at home. Patients typically referred to a skilled nursing facility following hospitalization will be eligible for enrollment. Instead of admission to a skilled nursing facility, participants will receive care from a technology-enabled team in their own homes or will be allocated to receive care in a traditional skilled nursing facility setting.

Inclusion 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)

Exclusion Criteria:

• 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