Skilled Nursing Facility Care at Home

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