Skilled Nursing Rehab at Home: The END for SNFs? | Occupational Therapist Thoughts

So a new study((Levine DM, Cueva MA, Shi S, et al. Skilled Nursing Facility Care at Home for Adults Discharged From the Hospital: A Pilot Randomized Controlled Trial. Journal of Applied Gerontology. 2022;41(6):1585-1594. doi:10.1177/07334648221077092)) was just published in the Journal of Applied Gerontology that investigated skilled nursing facility care ‘at home’ for adults discharged from the hospital. One option for patients who are not ready to go home from the hospital and who may need more medical care and attention as well as rehabilitation is going to a traditional skilled nursing facility, which some people refer to as a nursing home.

This study looked at providing a “similar” level of care as a skilled nursing facility, but instead of going to a skilled nursing facility, patients do rehab at home instead. I say similar in air quotes as you will see it’s not quite the same as a SNF. Note that this is different than a discharge home with traditional ‘home health’ therapy after staying at the hospital and getting therapy there. A skilled nursing facility provides a higher level of care to patients who need around the clock services such as nursing. So are SNFs in danger of closing down and should some healthcare providers worry about losing their jobs if they work in a SNF? Let’s check this study out.

So why are the researchers exploring a skilled nursing facility at home approach, or what they call a rehab at home approach, RAH for short? One point that they make is that SNFs have variable safety, quality, and experiences. Some Medicare patients experience adverse events that may have been preventable. Some of these events result in patients returning back to the hospital, which is unfortunate, because the goal is to instead go home. The second is cost and one proposed way to save on this is to change how it is paid, such as the location. As mentioned, there’s variability in safety and experience with SNFs. And I would argue of all these points made, safety is number one, as we as healthcare providers want to not only avoid doing harm but to help improve health outcomes.

So shifting the rehab site to home, how will they manage things like safety, which they argue would be better with this alternative approach? One way is with technologies and automation and shifting the task from humans to technologies. They use automatic continuous monitoring sensors, which is pretty cool, but I have my concerns with privacy. Some good points they make is that a home environment allows for the support and interaction of the family and of course, being home would be more comfortable. At least in theory. My thoughts on this is, well, not every home is a good environment for therapy. It could be distracting, dysfunctional, or even unsafe physically, or there could be family members who may be a barrier to therapy. For example, what if they have an alcohol problem or are abusive, even psychologically. So although there are often psychological benefits to being at home and recovering there, it could also be a barrier, depending on each individual patient’s circumstance.

So let’s look more at the study that they did. It was a pilot randomized control trial that assigned 10 participants to two groups. There was a RAH group and a control group, which was traditional SNF care. The participants were adults recruited from a hospital and were screened by case management to ensure that patients would benefit from SNF care. Inpatient physical therapy played a role in referring these patients for their appropriateness of going to a SNF. It would have been nice if occupational therapy was involved as well, I think, to address functional performance in occupations such as ADLs, IADLs, leisure, sleep, and health management. Conditions included cardiac, respiratory, orthopedic, and infections. Participants who were excluded were those who were on a ventilator, required hemodialysis, IV medications, or blood transfusion products. So this is a good majority of “traditional” SNF patients and makes these participants of the study, I would argue, “higher” level.

So what was their RAH intervention, the most interesting part, that makes it worth considering as an alternative to rehab at a traditional SNF setting? Once patients were home, they were assigned a certified CNA visit and a physician’s visit. The CNA was there to visit daily with a RN available for consult. So it’s important to note that no actual RN was on site, but instead a CNA at certain times of the day. So in terms of cost, this is lower. In a traditional SNF, you would have several nurses covering their caseload of patients. The CNA was the one who facilitated medications using an automated assistive technology that dispensed medications and was remotely programmable. So kind of cool. The physician was looped in via either phone call or video or text. Besides this, because the CNA was not there 24/7, there was a home health aide present 24 hours a day. So this covers the safety part, having a home health aide there 24/7. I would imagine it cuts down a little on cost as the home health aide cost is lower and the CNA and RN are not there, compared to a traditional SNF.

What about therapy intervention? PT provided their assessment remotely via virtual therapy sessions up to 3x daily. Home health aides assisted as needed with the therapy it seems, as they were physically present and the PT was not. Now I wonder since they mention ADLs and IADLs if the PTs were the ones who were doing these therapies instead of OT.

You may be wondering, well what about things like vitals? They did remote monitoring of vitals for things such as heart rate, respirations, even step count. Not sure how accurate the step count is, but its a good relative measure for therapists to have access to. Now what comes to mind is data privacy. How they handle this, what system they use, is this stored somewhere on the cloud, is it secure? Would love to know, as we live in the age of data being very sought after and valuable from a malicious actor standpoint.

Again, I did not see any mention of OT services, which is kind of disappointing. I realize this is a pilot study, but these participants could have benefited from a collaborative approach with PT and OT. Or maybe they had no OT needs. But they go on to measure ADLs and IADLs, so this implicitly implies the need for OT, so kind of confused here. 

What were the results? The RAH group had an increase in ADLs from a score of 2 to 4.5. In the control group, ADLs remained similar from 3 to 3.5. So this is not what I expected at all. I expected the SNF group to have higher ADL score changes, but the RAH showed an average higher score. Keep in mind there were only 10 total participants, so small sample size, and pilot study. So research is not generalizable to broader populations. But at the very least, the RAH group is at least as good and better than SNF in terms of ADL improvement. I am kind of skeptical that this pilot program produced “better” results for ADLs than a traditional SNF, but maybe we have been doing it wrong this whole time and should be looking at this data and this approach?

They measured IADL changes too and it was from 3 to 3.5 for the RAH group and from 4 to 4 for the control group. Health-related quality of life remained similar. They also measured steps but the authors state they may have been measured incorrectly. Patients apparently slept well, which is one benefit of this RAH, as it’s the familiar home environment, without the unnecessary sounds and stimuli going on at a traditional SNF. And last, patient experience was higher in the RAH group, which is another benefit. I bet it has to do with things such as having your own home-cooked meals and not having a roommate and having your own private space that is your own.

Another big finding worth mentioning is the cost. The RAH group cost on average about a rounded $8400, and the control group, which as traditional SNF, about a rounded $9200, factoring the point that both group’s lengths of stay were the same, at 14 days. So in their discussion, the authors state that the RAH pilot compared favorably to traditional SNF, with benefits of lower cost, greater functional improvement, and better patient experience. These are the triple aim points, by the way, that healthcare providers are trying to achieve. And they end with, this delivery method could reimagine how we deliver post-acute care, but more research is needed.

So what are some of my thoughts from this study. First, I was wrong about the cost thing. Apparently, one of the highest costs for this study was for the home health aide hours, not the other staff like CNA and RN, and this actually makes sense, as they were there 24/7. So it’s what probably helped with the cost savings. And from a discharge planning perspective no matter what initial setting to home, any time you have to recommend 24/7 around-the-clock care when hired, it is going to be very expensive. And not all patients have the finances to afford this, even if it is for a short duration. This study also relies heavily on the physical presence and availability of home health aides, which I would perceive there to be a shortage in staff and training and competency. You probably get a lot of variation in experience and safety competence so how it would have better safety than an entire team of staff of CNAs and nurses and therapists, I am kind of skeptical.

It also means that a RN is not there physically. So I would imagine some interventions like skin checks, how would they do that? I guess over telehealth or schedule a visit. Or things like dressing changes, IVs, and such were probably not done and needed. But this is a big portion of patients who go to a SNF, such as in ortho after elective surgeries or traumas.

It sounds like these patients are somewhat high level if PT and OT do not have to be there for therapy. So things like mobilizing to the toilet, dressing, and other ADLs. But then again, the participants experienced more “straightfoward” conditions such as pneumonia, fractures, and infections. Not ones that I am more used to seeing in neuro such as stroke and TBI, which would require intensive hands-on therapy such as mobilizing out of bed for transfers, ADLs, and IADLs. But the more that I think about it, this study seems like a more well-organized home health program with sensors, assistive tech like the medication dispensers, and telehealth. I wouldn’t technically call it a “SNF” at home so to say, as the participants are relatively stable medically and their therapy needs, although not explicitly mentioned, were achievable over telehealth. And again, no OT was mentioned. So it leads me to wonder, would these outcomes have been achieved another way anyways? Such as a shorter SNF stay and then home health? Or some other way entirely?

So what are your initial thoughts on this, especially for students who have done fieldwork at a SNF or OTs who have worked at a SNF? What are the pros and cons of this type of rehab?