Research Examines Quality, Outcomes from Subacute at Home Program.

Research Examines Quality, Outcomes From Subacute at Home Program.

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A young home care nurse walks with an elderly patient.

A research collaboration between the H.E.A.R. Institute, the Center for Successful Aging, and MedStar Health Home Care will examine the benefits of delivering subacute care for older patients at home.


With aging, there are times when patients need skilled nursing care, such as after surgery. Often, older adults are transferred to an inpatient nursing facility to receive this care. While this is the best option for some patients, research suggests that many seniors could benefit more from recovering at home. 

MedStar Health is well positioned to be a leader in the field with the expert personnel and  research infrastructure to make a difference. With this in mind, we are pioneering a patient-centered research and care collaboration between three MedStar entities or services that focus on providing evidence-based care for older adults:

The H.E.A.R. Institute and C.S.A. are investigating the potential benefits of at-home care after hospitalization and in-home care provider capacity to meet the growing need—by 2040, 25% of the U.S. population is expected to be older than 65. 

At the same time, H.E.A.R and C.S.A. are teaming up with MedStar Health Home Care to help more older patients get subacute care in their homes while closing gaps in communication and care that can result from changing facilities. If we can help people spend less time in subacute care facilities, they have a lesser chance of needing long-term care services, and we may be able to improve the aging experience.

Improving subacute care for seniors.

Aging increases the risk of chronic diseases, including dementia, diabetes, heart disease, and cancer, the nation’s leading causes of disability, death, and healthcare expenses.

Due to the natural aging process, hospitalized seniors are at risk of developing functional decline—difficulties with mobility and independence—after just a few days of an inpatient stay. Studies have shown that about 40% of patients discharged to subacute care facilities are either readmitted to the hospital or die.  

The collaboration between the H.E.A.R. Institute and the C.S.A. seeks to learn whether we can meet the growing demand for in-home subacute care and deliver improved quality at a reduced cost compared to inpatient care at a skilled nursing facility. With that knowledge, we hope to demonstrate that MedStar Health Home Care services benefit patients and healthcare systems—and we are actively enrolling patients in this innovative, skilled nursing at-home program. 

Related reading: Meet Lauren Bangerter, Ph.D., the New Head of Healthy Aging Research.

Meeting patients where they are.

The COVID-19 pandemic highlighted the ongoing desire of many patients to receive subacute care from the comfort of their homes. C.S.A. and MedStar Health Home Care have established a skilled nursing at-home program to serve this preference. 

To provide the best care, we develop coordinated plans to help our patients heal at home and create seamless care coordination. Making sure all types of providers are working together throughout the system reduces the likelihood of information gaps between patients, families, and providers through our revolutionary cross-team communication pathway.


How the subacute at-home program works.

To ensure care is coordinated and to improve outcomes, we’re helping patients heal at home after the hospital instead of in a skilled nursing facility. 

Our experts are looking for patients who are candidates for subacute care following a stay in the hospital. A provider may identify the need for ongoing skilled nursing services, including:

  • Injections
  • IV therapy
  • Monitoring of vital signs and medical equipment
  • Occupational therapy
  • Physical therapy
  • Speech-language pathology
  • Wound care
Typically, patients with these needs are discharged to a skilled nursing facility. In our Home Care program, we work to avoid that step when a patient’s health and home environment are conducive to healing with at-home skilled nursing care. Our criteria include:

  • A caregiver willing and able to support the patient
  • A safe environment
  • The ability to receive services

If the patient and home environment qualify, we enroll them in the program. It provides two hours of skilled nursing services in the home five to seven days per week for 30 days. In addition, the program offers:

  • The ability to contact a physician and/or nurse practitioner around the clock.
  • Virtual care visits in the home via telehealth or telephone.
  • Education, support, and empowerment for caregivers so they are better equipped to care for their loved ones after the program ends.
  • 20 hours per week of home health aide service to fill in gaps when the caregiver cannot be present.
  • Meals on Wheels and transportation to any in-person appointments.

Our experts work as a team to support all our patients’ needs. Team members include roles such as:

  • Care coordinators
  • Nurse practitioners
  • Pharmacists
  • Physical, occupational, and speech-language therapists
  • Physicians
  • Social workers

Our novel cross-team communication approach brings all the benefits of a skilled nursing facility into the patient’s home thanks to our team-based approach to care coordination. Weekly huddles ensure all patient care team members are involved and agree on the course of care. 

By reducing patients’ exposure to subacute care facilities, we hope also to short-circuit a cycle of readmission.
Research has shown that nearly 25% of patients on Medicare are readmitted to the hospital within 30 days, and this more than quadruples their likelihood of death within six months. We can do better.

After 30 days in our program, patients are transitioned to regular care from their primary care provider and other health support teams. Now, we’re working closely with our research colleagues to learn if the model of delivering skilled nursing care at home benefits patients.

Working for equity and quality in senior care.

The work of the Center for Successful Aging has been supported for many years by the generosity of the Arthur E. Landers and Hilda C. Landers Charitable Trust, and the skilled nursing at-home program is no exception. At its core, the subacute at-home program is an effort to advance health equity in the Baltimore area.

Through this program, we can provide top-quality technology and expertise to our patients, reducing the likelihood they will have to leave their homes for long-term care. Our collaboration with the H.E.A.R. Institute will help us learn better than ever before how to bypass inequities and disparities to provide the services our neighbors need most.

Want more information about this study?

Learn more about eligibility criteria and how to enroll.

Call 833-998-0900 or Contact

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