Lead Investigators:

Apurv Soni, MD, PhD; Peter Lindenauer, MD, MSc

Status Quo:

Post-acute care (PAC) is typically provided in skilled nursing facilities (SNFs) after hospital discharge to help patients recover. However, access to PAC can be limited, and traditional facility-based care may not always be convenient or preferable for patients. There is increasing interest in delivering PAC at home, but more research is needed to determine its effectiveness compared to SNFs.

What We Study:

The SNF at Home study aims to evaluate the effectiveness of home-based PAC compared to traditional SNF-based care. The study will enroll patients who need PAC and randomly assign them to receive either home-based or facility-based care after their hospital discharge. The goal is to understand if home-based care can provide similar or better outcomes for patients.

How We Innovate:

Participants in the home-based group will receive care from a clinical team at home, with daily visits and regular check-ins through telehealth. All participants will use the MyDataHelps app to report their health and wear a Garmin smartwatch to track key health metrics like step count, heart rate, and sleep patterns. The study also explores:

• Effectiveness: of home-based care compared to facility-based care.
  
  
• Satisfaction: patient satisfaction with home care.
  
  
• Digital Tools: use of smartwatches and apps to monitor health remotely.