RESUMO
OBJECTIVES: For patients who require frequent and intensive therapy services after hospitalization, rehabilitation is predominantly provided in skilled nursing facilities (SNFs). Delivering post-acute rehabilitation in patients' homes offers a potential alternative. Our aim was to describe and evaluate services and functional outcomes and then identify factors associated with the provision of a 30-day post-acute care (PAC) bundle of rehabilitation, medical, and social services provided via the Rehabilitation at Home (RaH) program. DESIGN: Single-arm retrospective review of patients participating in the RaH program. SETTING: Multidisciplinary home-based delivery of PAC in Manhattan. PARTICIPANTS: Individuals 18 years or older residing in a specified catchment area and qualifying for SNF-based rehabilitation services from October 2015 to September 2017. RESULTS: A total of 237 patients participated in RaH over 264 episodes of care. Participants were predominantly older than 85 years (57%; mean = 84.2; standard deviation [SD] = 10.0 years) and of non-Hispanic white (70%) race and ethnicity. Most were admitted after hospitalization (88.2%) for 117 different diagnostic related groups. Average length of stay in RaH was 14.2 (SD = 6.5) days with patients receiving 1.83 (SD = 2.22) medical provider, 1.67 (SD = 1.58) nursing, and 5.24 (SD = 1.05) physical therapist visits weekly. Most of the patients fully or almost fully met their goals for bed mobility (65%), bed transfer (69%), chair transfer (67%), and ambulation (64%) with the majority achieving moderate or considerable (61%) global functional improvement. Achieving moderate or considerable global improvement was negatively associated with dementia diagnosis (odds ratio [OR] = .23; 95% confidence interval [CI] = .08-.71) and positively associated with higher baseline ambulation (OR = 5.51; 95% CI = 2.22-13.66). At 30 days, 87.3% of participants were living in the community. CONCLUSION: Delivering SNF-level post-acute rehabilitation care in patients' homes for a broad range of diagnoses is feasible and associated with functional improvement. This approach may help older adults maintain living status in the community. J Am Geriatr Soc 68:1584-1593, 2020.